Every finding on record at Crest Nursing Home

Based on interview and record review, the facility failed to ensure a Director of Nursing (DON) worked full-time (defined by CMS as 40 hours or more per week) as the Director of Nursing. This failure increased the risk of negative outcomes for all residents. Findings include:During an interview on 5/4/26 at 12:30 p.m., staff member A stated the facility employed a full-time Director of Nursing and did not have any nurse staffing waivers in place.During an interview on 5/7/26 at 10:20 a.m., staff member B stated she is the infection preventionist and also the DON. Staff member B stated she dedicated 20 hours per week to infection control and the rest of her time to director of nursing responsibilities. During an interview on 5/7/26 at 11:40 a.m., staff member A stated staff member B could complete all her DON duties and infection control duties within a 40-hour work week due to the size of the facility and the low census. Staff member A stated staff member B never went into overtime. Staff member A stated they had always combined DON and infection control duties. Review of a letter provided by the facility with a date of 5/8/26, showed: If the DON requirement is only 35 hours, and if she spends 20 hours a week on Infection Prevention, that leaves 15 hours fully dedicated to other things. [sic]Review of the facility's Facility Assessment with a revision date of 2/11/26, showed: .Facility Resident Population: 1.1 Number of residents as of date of facility assessments completion: 44 .Administrative nurses: Infection control - tracking and trending, employee health, outbreak management Regulatory requirements Employee Health Quality Assurance/performance Improvement, Staffing and supply control including cost management MDS and quality measure information, five star ratings Pharmacy recommendations and consultant reports MD communications and Medical director communications Nurse Practice Act Resident's rights Fire safety Abuse identification, prevention and reporting Customer service .3.2 Position: .Other nursing personnel (e.g., those with administrative duties), MDS/CP RN, Director of Nursing. [sic]The facility assessment showed only two administrative nurses covering the facility's administrative nursing responsibilities.Review of a facility document titled Job Title: Director of Nursing Services, undated, showed: Summary: Responsible for the administration of the health care facility to maintain standards of resident care, and advises Department Heads, and the Administrator in matters related to nursing service by performing the following duties personally or through subordinate supervisors.Essential Duties and Responsibilities include the following. Establishes and implements an infection control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of disease and infection. [sic] The job description did not show the Director of Nursing position was a dual position and the DON would also be required to fulfill the Infection Preventionist role.

Based on interview and record review, the facility failed to protect a vulnerable resident from non-consensual sexual contact by a resident #22, who had a with a history of sexually inappropriate behaviors, for 1 (#1); and failed to monitor physical and psychosocial harm for 1 (#18) after an incident of abuse by resident #43, of 5 residents sampled for abuse by another resident. This failure resulted in resident #1 having her breast groped and bruising to resident #18's head and neck. Findings include:1. Review of a facility-reported event submitted to the State Survey Agency on 7/22/25, showed resident #22 was observed with one hand holding up resident #1's shirt while holding her breast with his other hand. During an observation and interview on 5/5/26 at 1:22 p.m., resident #22 was standing alone in the sitting room staring at the TV. Resident #22 stated he . touched someone's breast, and I am not allowed to do that. I have been good now. During a telephone interview on 5/5/26 at 1:40 p.m., NF1 stated he observed resident #22 lift resident #1's shirt with one hand while holding resident #1's breast with the other hand. NF1 stated when resident #22 saw him, he quickly removed his hand, and NF1 immediately removed resident #1 from the area. NF1 stated, He (resident #22) definitely knew his behavior was wrong. During an interview on 5/5/26 at 2:12 p.m., staff member A stated resident #1 was unaware of the incident, and no post-event psychosocial assessments were completed because she believed they were unnecessary, as the resident did not remember the incident. Staff member A stated if resident #1 showed behavior changes, it would have been documented in the nursing progress notes. Staff member A stated she was more worried about resident #22 than resident #1 after the incident. Staff member A stated resident #22 was issued a formal discharge; however, the resident remained in the facility due to placement challenges. Staff member A stated the facility immediately implemented interventions to prevent a future sexual incident, including escorting resident #22 to common areas and ensuring a six-foot distance from female residents. During an interview on 5/6/26 at 2:08 p.m., staff member H stated, [Resident #1] passed away in September last year. She was usually just pleasantly confused. Staff member H also stated resident #22 had a history of sexually inappropriate behavior toward female residents, which included long periods of stability where staff had no concerns, followed by periods of sexually inappropriate behavior. Staff member H stated since the 7/22/25 incident, nursing staff had been documenting inappropriate behavior for resident #22 once per shift, and CNAs were monitoring the resident's location once per hour. Staff member H stated no additional incidents had occurred. Staff member H stated she did not recall if any new interventions were implemented for resident #1 after the 7/22/25 incident. During a telephone interview on 5/7/26 at 1:13 p.m., NF2 stated after the 7/22/25 incident, resident #22's physician adjusted the resident's risperidone (antipsychotic) dose and added estradiol (estrogen) to reduce sexual behaviors. NF2 stated resident #22 had been on estradiol a couple of different times over the last couple of years for similar instances. Review of resident #1's Quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 7/18/25, showed a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Review of an incident report for resident #1 dated 7/22/25 showed special care remarks included, . redirect away from male resident [resident #22 initials] to at least six feet. Review of resident #1's electronic health record (EHR) did not show documentation of psychosocial evaluations related to sexual abuse. The EHR also did not show documentation of follow-up nursing progress notes, new tasks or interventions, or care plan updates pertaining to the 7/22/25 sexual abuse incident. Review of resident #22's quarterly MDS assessment, with an assessment reference date of 4/28/25, showed a Brief Interview for Mental Status score of 15, indicating intact cognition. Review of resident #22's physician progress note dated 4/2/25 showed the following diagnoses: paranoid schizophrenia, sleep disturbance, hypersexuality, and dementia without behavioral disturbance. Review of a facility social services note dated 7/23/25 at 3:37 p.m., showed, . I have contacted the police and they will be coming to serve him (resident #22) a ticket this afternoon and that we will need to issue him a discharge notice and try to get him transferred to another facility that is willing to provide this level of supervision ongoing, as we will not be able to provide it ongoing. [sic] Review of the facility's investigative documentation provided on 5/5/26 for the 7/22/25 sexual abuse incident showed staff and residents were asked whether they had witnessed a resident attempt to touch another resident inappropriately within the prior two weeks. The facility's investigative documentation also included a document titled 5 day follow up 7/25/25, which showed, Interviewed other residents and staff if they have ever seen anyone inappropriately touching or been touched by anyone in the facility and none had. 2. During an interview on 5/6/26 at 10:24 a.m., staff member F stated if resident #43 was tired, he would yell leave me alone. Staff member F stated the resident would reach out aggressively to staff when they were doing cares in pairs. Staff member F stated the resident was able to move his arms and legs. Staff member F stated the resident used to sit in the assisted dining room but eats in his room now because he hit other residents. During an observation on 5/6/26 at 12:45 p.m., resident #43 was seated in a wheelchair eating the afternoon meal in his room. At 12:46 p.m., staff member B entered the resident's room and assisted the resident with eating. During an interview on 5/6/26 at 1:36 p.m., resident #18 stated, . [abuse incident] has been a while ago. He (resident #43) doesn't eat in the dining room. He (resident #43) hit me as hard as he could. It hurt. He (resident #43) does that. He punches people . randomly. They stopped him (resident #43) from coming to the dining room. I don't have any more concerns. I feel safe. During an interview on 5/6/26 at 5:13 p.m., staff member B stated the facility followed up with resident #18. Staff member B stated resident #18 had not remembered the incident or it had not bothered him. Review of a facility reported incident, submitted to the State Survey Agency on 1/3/26, showed resident #43 was in the assisted part of the main dining room eating the morning meal. While staff had their back to him, resident #43 was able to move his wheelchair with one leg over to where resident #18 was seated and hit him in the neck and head. Resident #43 was removed from the dining room, away from other residents. Resident #43 had become agitated. Resident #43's care plan was updated to reflect the resident was to eat in his room if agitated or the activity room away from others if he was pleasant. Resident #18's care plan was updated to reflect the resident was to be seated away from resident #43. Resident #18's skin was checked for injuries and neurological checks were completed. Resident #18 had not shown any marks related to the incident. Review of the investigative findings, dated 1/8/26, showed resident #43's care plan was updated with interventions to eat in his room or the activity room depending on his mood and if there are other residents around. The resident was to have supervision during meals. He was also to be kept at least six feet away from other residents. The physician reviewed and made changes to the residents' medications. Review of a document, no title, dated 1/3/26, by staff member A showed three residents were interviewed regarding the incident and all three said they had never seen anyone kicked or hit prior to this incident. All three residents felt safe in the facility and had no concerns. The facility did not interview any other residents regarding abuse. Review of a facility document titled Continuing Education Record-Group, dated 1/3/26, showed education was completed for all staff on abuse and the reporting policy on 1/3/26 or before their next shift. Review of nursing progress notes dated 1/3/26, showed resident #18 was assessed with no abnormal physical findings. Review of resident #18's nursing progress notes for follow up after the incident, showed the following dates were documented as follow up to the incident 1/6/26, 1/8/26 and 1/9/26. On 1/6/26 there was a bruise on the back of the resident's neck which measured 6.3 cm X 5.2 cm. The facility had not documented daily physical and psychosocial assessments. There was one interview in which resident #18 stated he was doing fine. Review of a facility policy titled Resident Safety Abuse Policy, revised 2/22, showed: Providing a safe environment is one of the most basic and essential duties of the facility . Residents have the right to be free from abuse by anyone . Sexual abuse is non-consensual sexual contact of any type with a resident .

Based on observation, interview, and record review, the facility failed to ensure bed rails were assessed for entrapment, assessed for other alternatives, failed to ensure the bed rails had a documented medical rationale for the use of the bed rails, and failed to have a physician-signed order for the bed rails for 1 (#43) of 15 sampled residents. The failure placed the resident at risk for entrapment or injury from the use of bed rails. Findings include:During an observation on 5/5/26 at 4:30 p.m., resident #43 was lying in bed with full upper and lower bed rails on both sides of the bed.During an observation on 5/6/26 at 10:03 a.m., resident #43 was observed in bed. He was sleeping with his head tilted to the right with the head of the bed elevated. There were open areas on the upper and lower rails potentially creating a risk for entrapment. There was space between the upper and lower rails, potentially creating a risk for entrapment.During an interview on 5/6/26 at 10:17 a.m., staff member F stated resident #43 was to have all four rails up while in bed. Staff member F stated resident #43 was evaluated by physical therapy. Staff member F stated there was always someone in the room during repositioning. Staff member F stated the resident could possibly reposition himself. Staff member F stated the nurse signed with the POA on the consent form for only the upper bed rails.During an interview on 5/6/26 at 4:59 p.m., staff member B stated resident #43 suffered from a traumatic brain injury which caused aggressive behavior and was not easily redirected. Staff member B stated the rails on the resident's bed were to keep him from falling off the bed. Staff member B stated the goal was to get the resident stronger through physical therapy so he could go home.During an interview on 5/7/26 at 7:49 a.m., staff member B stated the resident used the rails for repositioning.During an interview on 5/7/26 at 8:35 a.m., staff member G stated she was the one who had done the assessment for resident #43's upper bed rails. Staff member G stated nursing completed the assessment for the lower bed rails. Staff member G stated she signed consent with resident #43's family member for the upper rails.During an interview on 5/7/26 at 10:14 a.m., staff member B stated the bed rails should be assessed every quarter and/or as needed. Staff member B stated all staff members should check the bed rails on every round. Staff member B stated nursing completed the lower rail assessment and they conferred with physical therapy. Staff member B stated there should be a physician order for the use of the bed rails. Staff member B stated resident #43 was impulsive and kicked his legs a lot which caused a risk for falls. Staff member B stated the bed rails were for safety reasons.The facility failed to consistently identify a reason for the use of the bed rails and failed to ensure staff were aware of a documented reason for the bed rails. Review of resident #43's care plan, with a current date of 1/28/26 for the bed rails showed the facility documented inconsistent reasons for the bed rails.Review of resident #43's bed rail consent forms showed one was signed by the DON and the resident's family member on 10/29/25 for the lower rails, and one was signed by physical therapy and the POA on 10/31/25 for the upper rails. The consent form, dated 10/29/25, showed the indication for lower rail use was, for TBI, impulsive, agitation, request of family. The consent form, dated 10/31/25, showed the indication for upper rail use was, for ^ (increased) bed mobility. [sic] Resident #43's care plan, dated 11/24/25, 1/3/26, and 1/28/26, failed to show alternative interventions for the rationale to continue the use of the bed rails.Review of resident #43's bed rail assessment, dated 10/30/25, showed the rails were for . assistance with bed mobility, to prevent rolling and falling out of bed, and for comfort and security. Plan . device appropriate, obtain consent and obtain order. Review of resident #43's care plan showed: . -11/24/25 Problem; Potential for sleep pattern disturbance and difficulty sleeping with early awakening.Use side rails on bed to decrease risk of fall with increased agitation.-1/3/26 Problem; Potential for disruptive interaction, aggression and/or agitation.Use side rails on bed to decrease resident falling to the floor with agitation.-1/28/26 Problem; Potential for trauma and falls with injury.Use side rails on bed to decrease risk of fall to floor with agitation.The facility failed to provide a signed physician order for the bed rails, failed to complete an assessment for potential entrapment, failed to document a rationale for the use of the bed rails, and failed to document alternatives used prior to use of bed rails.

Based on observation, interview, and record review, the facility failed to revise a care plan to include interventions that were effective in monitoring the bed rails for a resident's ongoing use of the rails, for 1 (#43) of 15 sampled residents. This failure caused the staff to provide inconsistent reasoning for the use of the bed rails. Findings include:During an observation on 5/6/26 at 10:03 a.m., resident #43 was observed in bed with upper and lower bed rails in place. Both upper and lower bed rails had open areas for potential entrapment of arms, and there was space between the upper and lower bed rails which could have the potential for entrapment of a limb.During an interview on 5/6/26 at 10:17 a.m., staff member F stated all four rails were to be up while resident #43 was in bed. Staff member F stated the bed rails help with repositioning. Staff member F stated there was always someone in the resident's room during repositioning. During an interview on 5/6/26 at 1:36 p.m., staff member C stated bed rails were part of the MDS assessment, and interventions should be on the care plan. Staff member C stated bed rails should be reassessed when there is a change in condition, general nursing assessment, and should be a part of the quarterly assessment.During an interview on 5/7/26 at 8:35 a.m., staff member H stated staff member G was responsible for assessing the need for upper bed rails. Staff member H stated staff member G would add bed rails and interventions into the care plan.During an interview on 5/7/26 at 10:14 a.m., staff member B stated the bed rails should be assessed every quarter and as needed. Staff member B stated the interventions should be reviewed and revised at least quarterly. Staff member B stated the care plan showed the staff was to observe to ensure the bed rails were up.Review of resident #43's care plan, dated 11/24/25, showed the potential for sleep pattern disturbance, with difficulty falling asleep and early morning awakening. Interventions included the use of rails on the bed, . to decrease the resident fall with increased agitation.Review of resident #43's care plan, dated 1/3/26, showed potential for disruptive interaction, aggression, and/or agitation. Interventions include . use side rails on the bed to decrease falls to the floor with agitation.Review of resident #43's care plan, dated 1/28/26, showed potential for trauma and falls with injury. Interventions included, . use side rails on bed to decrease risk of fall to floor with agitation.

Based on interview and record review, the facility failed to ensure the director of food and nutrition services met the education qualifications required by CMS for a food service director and failed to employ a full time Dietician, which increased the risk of negative outcomes to residents receiving food from the dietary department. Findings include:During an interview on 5/5/26 at 3:09 p.m., staff member E stated she did not have a dietary manager certification. Staff member E stated she had not enrolled or completed an approved dietary manager certification course. Staff member E stated the dietician came to the facility once every two weeks to evaluate the residents. Staff member E stated she would call the dietician if she had questions or concerns. During an interview on 5/6/26 at 1:22 p.m., staff member A stated that staff member E had not completed a dietary manager certification course but had five years of experience in dietary management before being hired in 2024. Staff member A stated she had been under the impression that staff member E's prior experience was enough to meet the CMS requirement for dietary managers. Staff member A stated the dietician visited the facility twice a month, and the facility has a remote dietician who assisted with menus and other dietary duties. Staff member A stated the facility did not employ an onsite full-time dietician.Review of staff member E's education provided by the facility showed staff member E had completed continuing education hours in multiple different areas but failed to show staff member E had completed a certified dietary manager course. Review of a facility document titled Job Title: Food Service Manager showed: .Qualifications Requirements: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Certificates, licenses, registrations: Successful completion or current enrollment in a course approved by American Dietetic Association. [sic]

Based on interview and record review, the facility failed to remove or replace binding arbitration language as required from the facility admission agreement, for 2 (#s 36 and 198) of 2 sampled residents for arbitration agreements. This deficiency had the potential to affect all residents being admitted to the facility signing the admission agreement. Findings Include: During an interview on 4/7/25 at 11:50 a.m., staff member A stated the facility did not do arbitration at all. Staff member A stated the arbitration information was taken out of the admission agreements when the law was changed. During an interview on 4/8/25 at 4:35 p.m., staff member A stated she was directed to leave in the arbitration parts of the admission agreement and just handwrite an 'N/A' by each section related to arbitration. She directed her staff not to review the arbitration information since they no longer did arbitration. During an interview on 4/9/25 at 10:18 a.m., staff member C stated from her understanding, since she started, she was to use the admission agreement copies with the N/A by the binding arbitration areas in the miscellaneous section and not review it with residents or representatives. Review of the facility document, Resident Admission Agreement: VIII Miscellaneous, not dated, showed on page two for the resident or representative authorized to sign the agreement, .to enter into and bind the Resident to each and every term and condition of this Agreement and its Exhibits, both financial and non-financial, including Section VIII.G. (Arbitration of All Disputes) and its accompanying Exhibit A, without restriction whatsoever. the Representative understand and acknowledges that this Facility will seek to enforce, without exception, the terms and conditions of this agreement and its Exhibits in full and reasonable reliance thereof. Under VIII. Miscellaneous sections, E. BINDING ON PARTIES AND OTHERS . F. GOVERNING LAW . G. ARBITRATION OF ALL DISPUTES . H. WAIVER OF JURY TRIAL . I. SURVIVAL OF AGREEMENTS TO ARBITRATE . J a. Binding Arbitration Agreement . [sic] each had a handwritten N/A over the letter headings with all binding arbitration verbiage still listed. The only area for signature was on the last page of the attached exhibit with arbitration. The required information for having arbitration agreements was not in the document. There were no dates or initials to show when the arbitration parts were no longer included or for residents or their representatives to decline those areas. Review of signed resident admission agreements for residents #36 and #198, showed each agreement on the first page had a paragraph that stipulated they were consenting to enter into a binding agreement including arbitration. Each had a different handwritten N/A by the sections for binding arbitration. The arbitration language did not include the required information and declination for residents or their representatives. No other initials or dates to show when or who put N/A for the binding arbitration sections of the admission agreement. The only signature line was to accept the agreement. Resident #36's admission agreement with the arbitration language was signed on 5/20/24. Resident #198's admission agreement with the arbitration language was signed on 3/31/25.

Based on observation, interview, and record review, the facility failed to ensure a resident's medical record was accurate for 1 (#36) of 15 sampled residents when an unsigned POLST was removed, but then replaced, in the residents active medical record. Findings Include: During an observation and record review on 4/8/25 at 10:06 a.m., resident #36's hard chart had a green POLST form under the front tab. The POLST showed the selections of DNR, selective treatment, and no tube feeding, and it was signed by resident #36 on 5/20/24. There was no physician signature, therefore, the POLST would be invalid. During an interview on 4/9/25 at 10:09 a.m., staff member F stated in the event of a resident emergency they would check the POLST in the hard chart unless they already had the EMR pulled up to check the code status. The POLST was checked because that, and the facesheet, would be provided to emergency services. During an interview on 4/9/25 at 10:18 a.m., staff member C stated since she started in the position she was directed to have the residents fill out a new POLST and advance directive information to make it accurate and up to date. Once the resident completed the POLST their choice of code status was added to the EMR before the provider signed the POLST. During an interview on 4/10/25 at 10:10 a.m., staff member A stated resident #36's POLST was not signed due to her identifying the resident did not have the mental capacity to make healthcare decisions. Staff member A stated she took the POLST out of her hard chart and somehow it was put back in. Review of resident #36's hard chart showed the green POLST, dated 5/20/24, not signed by a provider still in the chart.

Based on observation, interview, and record review, the facility failed to ensure a portable oxygen tank was replaced when the metered volume was empty, with the resident's oxygen saturation at 86%, for 1 (#6); and failed to ensure licensed nursing staff documented provider notification, nursing assessments, and/or nursing interventions of resident's oxygen saturation levels below the parameters set forth in written orders of 90% for 2 (#s 5 and 6) of 3 sampled residents receiving supplemental oxygen. Findings include: 1. Resident #6 During an observation on 3/24/25 at 11:17 a.m., resident #6 was seated in her wheelchair, in the hallway, outside of her room. Resident #6 had a portable oxygen tank attached to her chair, which showed the pressure gauge needle at approximately 1,500 psi. During an interview on 3/24/25 at 12:33 p.m., staff member D stated all staff were responsible for checking the oxygen levels on the resident's portable oxygen tanks. Staff member D stated, regarding the pressure gauge of the oxygen tanks, when the needle on the gauge was in the red, the tank needed to be replaced. She stated if the needle on the oxygen tank was close to the red area, she would make a mental note to continue to check the gauge constantly. Staff member D stated if the needle on the gauge was really close to the red area and she was afraid the tank would run out, she would just go ahead and change out the oxygen tank. During an interview on 3/24/25 at 12:51 p.m., NF1 stated he had seen resident #6's portable oxygen tank empty (with the needle of the gauge in the red) several times. NF1 stated he was very worried about resident #6's oxygen levels, with readings as low as 74%, and the facility not changing out her portable oxygen tank when it was empty. NF1 stated he had taken his concerns to the administration of the facility. During an observation on 3/25/25 at 8:00 a.m., resident #6 was seated in the dining room for breakfast. Resident #6's portable oxygen tank needle read approximately 1,000 psi on the gauge. During an interview on 3/25/25 at 8:28 a.m., staff member C stated the staff check the oxygen levels on the resident's portable tanks constantly. During an observation on 3/25/25 at 10:00 a.m., staff member A was changing out residents' portable oxygen tanks in the common/activity area of the facility. During an observation on 3/25/25 at 10:10 a.m., resident #6's portable oxygen tank's needle was at the bottom of the red area, on empty. Staff member C was asked about the empty tank and stated they (staff) would change the tank. Staff member C used the pulse oximeter to read resident #6's oxygen level, which was 86%. Review of resident #6's EHR document, titled Treatment Administration Record (Summary Report), printed 3/25/25, showed the following order and documentation: - . Entry Date: 11/22/2024 RESPIRATORY TREATMENT: Apply oxygen O2 Saturation 2L continuous (per nasal Cannula) r/t heart failure to keep O2 sat > or equal to 90 % AM PM NOC noc O2 Sat: am O2 Sat: pm O2 Sat. [sic] - All occurrences and omissions for resident #6, from 11/1/24 through 3/24/25, showed oxygen readings were below 90% or not documented in the record, without any provider notification or documentation of further interventions. - November 2024 showed one occurrence out of 23 entries, - February 2025 showed three occurrences out of 76 entries, and -March (3-1-25 through 3-24-25), showed three occurrences and 20 omissions out of 72 possible entries. Review of resident #6's EHR document, titled Treatment Administration Record (Summary Report), printed 3/25/25, showed the following order and documentation: - . Entry Date 03/25/2024 NURSING ORDER: Check O2 Concentrator or Portable Tank to ensure turned on and at 2L NC AM PM NOC first date: 02/25/2024. [sic] - All omissions for resident #6, from 10/1/24 through 3/24/25, showed no documentation to ensure the oxygen was turned on and set at two liters per minute. - October 2024 showed one omission. - November 2024 showed two omissions, - December 2024 showed six omissions, - January 2025 showed four omissions, - February 2025 showed four omissions, and - As of 3/24/25, March 2025 showed nine omissions. 2. Resident #5 During an observation on 3/24/25 at 11:33 a.m., resident #5 was seated in the dining room. Resident #5 was receiving supplemental oxygen, via nasal cannula, from a portable oxygen tank. Review of resident #5's EHR document titled, Treatment Administration Record (Summary Report), printed 3/25/25, showed the following order and documentation: - . Entry Date: 03/12/2024 RESPIRATORY TREATMENT: Oxygen 1lpm via NC to maintain Sp02 >90% for hypoxemia.at bedtime NOC noc O2 Sat: AM am O2 Sat: PM pm O2 Sat. [sic] - All occurences for resident #5 for September 2024 through January 2025, showed licensed nursing staff failed to document any provider notification, nursing assessments, and/or nursing interventions of resident's oxygen saturation levels when they fell below 90%. - September 2024 showed five occurrences out of 89 entries, - October 2024 showed six occurrences out of 90 entries, - November 2024 showed 15 occurrences out of 88 entries, - December 2024 showed seven occurrences out of 91 entries, and - January 2025 showed seven occurrences out of 86 entries. During an interview on 3/25/25 at 10:25 a.m., staff member F stated she checked the resident's vital signs, including oxygen levels. She stated if a resident had a oxygen level below 90%, she would report the reading to the nurse. During an interview on 3/25/25 at 10:28 a.m., staff member D stated CNAs checked resident's vital signs. She stated if any part of the vital signs were outside of the resident's normal, the CNAs would report to the nurse. Staff member D stated if the resident's oxygen level readings were below 90%, then an assessment would be completed, notification to the provider, and what interventions were performed, all documented in the resident's record. During an interview on 3/25/25 at 10:38 a.m., staff member G stated resident's portable oxygen tanks were checked each shift to make sure oxygen levels were correct. Staff member G stated we (staff) periodically check tank oxygen levels and some residents will tell staff when their oxygen is empty. Staff member G stated nurses and CNAs checked vital signs. She stated a CNA would report to their nurse if a resident's oxygen level was below 90%. Staff member G stated if a resident's oxygen level was below 90%, she would check to see why the oxygen was low and would call the provider for further interventions. Staff member G stated she would chart on the resident's oxygen levels exception in their record. During an interview on 3/25/25 at 12:28 p.m., staff member A stated CNAs did vitals, which was written on the CNA sheet, which was part of the care plan. Staff member A stated if vitals were outside of the normal, the CNA would report to the nurse. She stated the nurse would then further assess the resident and the provider would be notified of changes in the oxygen levels. Staff member A stated the vitals, assessment completed, notification to the provider, and any interventions should be documented in the resident's record.

Based on interview and record review, the facility failed to ensure licensed nursing staff adhered to accepted standards of practice by only administering oxygen within the parameters of provider's orders for 3 (#s 4, 5, and 6) of 3 sampled residents prescribed supplemental oxygen. Findings include: 1. Resident # 5 Review of resident #5's EHR document, titled Treatment Administration Record (Summary Report), printed 3/25/25, showed the following order and documentation: - . Entry Date: 03/12/2024 RESPIRATORY TREATMENT: Oxygen 1lpm via NC to maintain Sp02 >90% for hypoxemia.at bedtime NOC noc O2 Sat: AM am O2 Sat: PM pm O2 Sat. [sic] - All occurrences for resident #5, from 9/2024 through 3/20/25, showed professional nursing staff documented the oxygen levels delivered exceeded the prescribed one liter per minute. - September 2024 showed 14 occurrences out of 89 entries, - October 2024 showed 45 occurrences out of 90 entries, - November 2024 showed 42 occurrences out of 88 entries, - December 2024 showed 55 occurrences out of 91 entries, - January 2025 showed 21 occurrences out of 86 entries, - February 2025 showed 24 occurrences out of 77 entries, and - March 2025 showed 46 occurrences out of 53 entries. Review of resident #5's EHR document, titled Treatment Administration Record (Summary Report), printed 3/25/25, showed the following order and documentation: - . Entry Date: 3/20/25 RESPIRATORY TREATMENT: Oxygen 1lpm via NC to maintain SpO2>90% for hypoxemia continuous to keep oxygen sats at 90% equal to or greater NOC noc O2 Sat: AM am O2 Sat: PM pm O2 Sat . [sic] - 3/20/25 through 3/24/25, showed six occurrences out of 13 entries for resident #5, in which oxygen documented as delivered exceeded the prescribed one liter per minute. 2. Resident #6 Review of resident #6's EHR document, titled Treatment Administration Record (Summary Report), printed 3/25/25, showed the following order and documentation: - . Entry Date: 03/25/2024 RESPIRATORY TREATMENT: Apply oxygenO2 Saturation 2L continuous (per nasal cannula) to keep O2 sat > or equal to 90 % AM PM NOC noc O2 Sat: am O2 Sat: pm O2 Sat. [sic] - All occurrences for resident #6, from 10/1/24 through 11/22/24, showed professional nursing staff documented the oxygen levels delivered exceeded the prescribed two liters per minute. - October 2024 showed 31 occurrences out of 91 entries, and - November 2024 (through 11/22/24) showed 16 occurrences out of 61 entries. Review of resident #6's EHR document, titled Treatment Administration Record (Summary Report), printed 3/25/25, showed the following order and documentation: - . Entry Date: 11/22/2024 RESPIRATORY TREATMENT: Apply oxygen O2 Saturation 2L continuous (per nasal cannula) r/t heart failure to keep O2 sat > or equal to 90 % AM PM NOC noc O2 Sat: am O2 Sat: pm O2 Sat. [sic] - All occurrences for resident #6, from 11/23/24 through 1/31/25, showed professional nursing staff documented the oxygen levels delivered exceeded the prescribed two liters per minute. - November 2024 (11/23/24 - 11/30/24) showed one occurrence out of 23 entries, - December 2024 showed five occurrences out of 86 entries, and - January 2025, showed two occurrences out of 88 entries. 3. Resident #4 Review of resident #4's EHR document, titled Treatment Administration Record (Summary Report), printed 3/25/25, showed the following order and documentation: - . Entry Date: 02/02/2024 RESPIRATORY TREATMENT: evaluate continued oxygen need at night : Administer oxygen 1-2lpm via NC at night to maintain Spo2 equal or greater than 90%. for Resp Failure with hypoxiaNOC noc O2 Sat: first date: 02/02/2024 May titrate to room if SpO2 90% or greater on room air. [sic] - All occurrences for resident #4, from 11/1/24 through 1/31/25, showed professional nursing staff documented the oxygen levels delivered exceeded the prescribed maximum of two liters per minute. - November 2024 had eight occurrences out of 30 entries, - December 2024 had 21 occurrences out of 31 entries, and - January 2025 had two occurrences out of 26 entries. Review of resident #4's EHR document, titled Treatment Administration Record (Summary Report), printed 3/25/25, showed the following order and documentation: - . Entry Date 12/20/2024 RESPIRATORY TREATMENT: Portable O2 tank 1L - 2L nasal cannula when outside the room. Related to Respiratory failure. noc O2 Sat: am O2 Sat: pm O2 Sat. [sic] - 12/20/24 through 12/31/24 had seven occurrences out of 33 entries, showed professional nursing staff documented the oxygen levels delivered exceeded the prescribed maximum of two liters per minute. During an interview on 3/25/25 at 10:28 a.m., staff member D stated nursing was the only discipline allowed to change oxygen levels on the residents' oxygen concentrators or portable tanks. She stated a nurse would need new provider orders to change a resident's oxygen rate of flow, if it was outside the existing order parameters. Staff member D stated oxygen was considered a drug. During an interview on 3/25/25 at 10:38 a.m., staff member G stated a nurse needed provider's orders to change the rate of flow for a resident's oxygen. During an interview on 3/25/25 at 1:10 p.m., staff member A stated nurses were to always follow the provider's orders for the delivery rate of oxygen. Review of the facility document titled, Oxygen - Appropriate Use, Management and Storage, last revised 1/25, showed: - . 1. Oxygen Orders: - a. Treat oxygen as a medication. As with any drug, continuously monitor the dosage or concentration of oxygen and routinely check the provider's orders to verify that the patient is receiving the prescribed oxygen concentration. - . 2. Oxygen Management: - . b. The licensed nurses MUST follow a physician order for oxygen delivery.

Based on observation, interview, and record review, the facility failed to change and label resident oxygen tubing for 4 (#s 4, 28, 33, and 34) of 5 sampled residents for respiratory care. This deficient practice had the potential to increase the incidence of respiratory disease for residents using supplemental oxygen in the facility. Findings include: 1. During an observation on 3/26/24 at 2:58 p.m., resident #34 was lying in bed with a nasal cannula on. The cannula tubing was labeled and dated, on a piece of tape, as 3/13, thirteen days prior. During an interview on 3/26/24 at 3:27 p.m., NF2 stated he had concerns about resident #34's oxygen. NF2 stated he felt the staff had not been paying attention to the resident's oxygen level and did not think they were looking at her tubing. During an observation and interview on 3/27/24 at 1:28 p.m., staff member G was changing the tubing on resident #34's oxygen concentrator. Staff member G stated resident #34's tubing was changed every Wednesday and was dated with a piece of tape on the tubing. Staff member G stated resident #34's oxygen tubing should have been changed last Wednesday on 3/20/24. During an interview on 3/27/24 at 4:24 p.m., NF3 stated prior to her admission to the facility, resident #34 was in the hospital for respiratory failure with hypoxia (lack of oxygen), and had been titrated down to two liters of oxygen. During an interview on 3/28/24 at 8:15 a.m. with staff members A and C, staff member A stated she expected the nursing staff to change oxygen tubing, and the tubing should have been labeled with tape, or something easily seen. Staff member C stated nurses could delegate oxygen tubing changes to the CNAs, but the nurses often changed it themselves. Review of resident #34's TAR showed, RESPIRATORY TREATMENT: Change oxygen tubing 1 x wk (week). Wednesday AM first date: 10/18/2023. The TAR showed the oxygen tubing was charted as completed on 3/20/24 by staff member F. 2. During an observation on 3/26/24 at 2:52 p.m., resident #33 was in bed, and had a nasal cannula on, and the tubing was without a label containing the date it was last changed. During an observation on 3/27/24 at 1:37 p.m., resident #33 was sitting up in his wheelchair, with his nasal cannula on, and the tubing was undated. During an interview on 3/27/24 at 2:43 p.m., staff member H stated the nursing staff knew to change the oxygen tubing based on the date on the piece of tape on the oxygen tubing. Staff member H stated if she did not see a piece of tape on oxygen tubing, I would just change the tubing and write the date on a piece of tape. The tubing is supposed to be changed once a week. Review of resident #33's TAR showed an order for, RESPIRATORY TREATMENT: Change oxygen tubing with equipment maintenance 1 x wk. daily AM Saturday first date: 03/16/2024. The TAR showed the resident received the tubing change on 3/23/24. Review of resident #33's EMR showed diagnoses for Pneumonia, Chronic Obstructive Pulmonary Disease, and Obstructive Sleep Apnea. 3. During an observation and interview on 3/26/24 at 2:46 p.m., resident #4 was lying in bed, with a nasal cannula on. The oxygen tubing was not labeled with a date of when it was last changed. Resident #4 stated she was always on oxygen due to COPD. During an observation on 3/27/24 at 1:39 p.m., resident #4's oxygen tubing was labeled with a piece of tape with the date 3/27. During an interview on 3/27/24 at 1:43 p.m., staff member F stated the protocol for oxygen tubing change included whoever changed the oxygen tubing, would put a piece of tape on it, with the date it was changed. Review of resident #4's TAR showed an order for, RESPIRATORY TREATMENT: Change oxygen tubing with equipment maintenance 1 x wk. daily AM Saturday first date: 03/16/2024. The TAR showed the resident received the tubing change on 3/23/24. Review of resident #4's EMR showed diagnoses of Chronic Respiratory Failure and Chronic Obstructive Pulmonary Disease. 47785 4. During an observation on 3/27/24 at 1:40 p.m., there was no tape on the oxygen tubing, showing the date when the oxygen tubing was last changed, for resident #28. Review of resident #28's electronic medical record showed the tubing was scheduled to be changed weekly. Review of the facility's policy, Oxygen - Appropriate Use, Management and Storage, reviewed 1/2024, showed: 2. Oxygen Management: .e . For oxygen supply changes, please ensure that in addition to the provider order for a 7-day (weekly) supply change, that you also document the weekly supply change in the eTAR and date/initial the supply change on the product when put into use .

Based on interview and record review, the facility failed to ensure a resident's GDR request was responded to by the physician, and completed, for 1 (#34) of 5 sampled residents for unnecessary medications. Findings include: Review of resident #34's MAR showed a physician order for, FLUoxetine HCI 40MG Capsule dose ordered: (1 capsule / 40mg) by mouth daily AM FOR: Depression. Administration Instructions: MEDICATION TO BE GIVEN WITH FLUOXETINE 20MG FOR A TOTAL OF 60MG. Review of resident #34's Consultant Pharmacist's Progress Notes showed: - January 2024: GDR for fluoxetine: Started on 20 mg daily on May 2, 2022 for 14 days, then increased to 40 mg daily. Dose reduced to 20 mg once daily on March 2, 2023. Dose increased to 40 mg once daily on May 3, 2023. Dose increased to 60 mg once daily on May 31, 2023. - February 2024: GDR for fluoxetine: . Dose increased to 60 mg once daily on May 31, 2023. No response to request sent in [DATE]. - March 2024: GDR for fluoxetine: . No response to request sent in [DATE]. Surveyors requested the Fluoxetine GDR request from the pharmacy for January 2024, for resident #34, on 3/27/24 at 5:12 p.m. Review of the facility provided request form showed it was completed on 3/27/24, the day it was requested by the survey team. During an interview on 3/28/24 at 7:47 a.m., staff member A stated the GDR response for resident #34 was completed by the physician the day prior, 3/27/24, and she would talk to staff member D about timeliness of the required GDR completions. During an interview on 3/28/24 at 8:10 a.m., staff member A stated staff member B was responsible for ensuring GDR requests were responded to by the physician, and for ensuring conversations with providers, about GDRs, were documented. Staff member A stated staff member D was probably waiting to respond due to the resident's hospice status, but there was no documentation of this. Review of the facility's policy, Psychoactive Medication Protocol, revised 10/22, showed: . 12. Required Gradual Dose Reductions: a. Compliance with the requirement to perform a GDR may be met if, for example, within the first year in which a resident is admitted on a psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, a facility attempts a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated.

Based on observation and interview, the facility failed to employ sufficient dietary staff, which caused the resident meals to be served late. This had the potential to affect residents in the building who received meals. Findings include: During an interview on 9/13/21 at 11:20 a.m., staff member E stated meals are served at 7:30 a.m., 11:30 a.m., and at 4:30 p.m. Staff member E was assisting with meal service in the dining room. During an observation on 9/14/21 at 7:20 a.m., staff member D had prepared cream of wheat and bacon for breakfast. Staff member D stated she makes the eggs to order and had not made them yet. There were only two dietary staff members in the kitchen to serve breakfast at that time. During an observation on 9/14/21 at 8:10 a.m., staff member D started meal service for the dining room, 40 minutes after it was scheduled to start. There were only two dietary staff in the kitchen for meal service at the time. The last breakfast meal tray, for the residents, was served on one of the units at 9:15 a.m., one hour and forty-five minutes after the start of breakfast. The facility managers and corporate staff were observed serving breakfast trays in the dining room to the residents. There were no CNAs (certified nursing assistants) serving the breakfast meal during the observation. During an observation and interview on 9/14/21 at 9:05 a.m., staff member D was waiting for her aide to return, after passing trays to residents who ate in their room. Staff member D stated she waits to load the last trays because They (food) get cold by the last resident. During an observation on 9/14/21 at 9:14 a.m., staff member D was starting to prepare the final trays to be passed, requiring Staff member D to reheat bacon on the grill, and the toast in the microwave for the last meals. The final meal trays left the kitchen at 9:20 a.m. The final tray was delivered at 9:28 a.m. Staff member D took temperatures of the meal: Hot Cereal was at 106.8 degrees F, Eggs were at 104.6F, and hash browns were at 104.2F. The food was served to the residents almost a full two hours after the morning meal was to start. During an interview on 9/15/21 at 7:47 a.m., staff member P stated the staff serve the room trays after the dining room, and the meals are usually about thirty minutes late. Staff member P stated she did not feel there was enough staff to have all residents receive their meals in a timely manner. During an observation on 9/15/21 at 8:16 a.m., the last hall tray was served, which was forty six minutes after the start of breakfast.

Based on observations, interview, and record review, the facility failed to use proper hand hygiene practices while performing peri care for 2 (#s 2 and 11) residents; failed to sanitize a mechanical lift before and or after use for 1 (#14) resident; failed to ensure the flooring in the bathroom for 1 (#30) resident had a cleanable surface area; and failed to perform proper hand hygiene prior to a dressing change for 2 (#s 8 and 343) of 24 sampled and supplemental residents. Findings include: 1. During an observation and interview on 9/14/21 at 3:00 p.m., staff members I and J provided peri care for resident #2. Both staff members knocked, sanitized their hands, and donned gloves. Resident #2 was lying in bed. Staff member I and J rolled resident #2 from the left side, staff member J wiped the resident's peri area. Staff members I and J then rolled the resident to the right side, and staff member I wiped the resident's peri area, removed the soiled incontinent brief, and placed it in the trash. Staff member I removed his gloves, placed a clean incontinent brief under resident #2, and rolled her onto her back and to her other side. Staff member J adjusted the incontinent brief, assisted the resident to her back, and both staff members pulled her pants up and placed a transfer sling under her. Staff member I and J did not wash or sanitize their hands after removing their gloves. Staff member I stated hands should be washed or sanitized before and after resident care if they are soiled. 2. During an observation and interview on 9/15/21 at 9:10 a.m., staff members B and L provided peri care for resident #11. Staff member L sanitized her hands and donned gloves. Staff member L then opened the dresser drawers to look for wipes and a clean incontinent brief. Staff member L, pulled the covers back, unfastened resident #11's brief, pulled the clean wipes out of the container, and wiped the residents front peri area. Staff member L then covered resident #11 up while waiting for staff member B. Staff member L did not remove her gloves or sanitize her hands from a soiled to clean task. Staff member B entered the room, sanitized her hands, and donned gloves. Staff member L pulled the blanket back, lowered the head of the bed, rolled resident #11 to her right side, removed the soiled incontinent brief, and wiped the resident's back side of a small amount of stool. Staff member L removed the soiled incontinent brief, placed it in the garbage, and placed a clean incontinent brief under resident #11. Staff member B applied ointment to resident #11's peri area, removed her gloves, and sanitized her hands. Staff members B and L rolled the resident to her back. Staff member L wiped resident #11's front peri area again, pulled the incontinent brief from between her legs, and fastened the brief. Staff members B and L then removed a turn blanket from under the resident, placed a pillow under her legs, and raised the head of her bed. Staff member L removed her gloves, placed the turn blanket in a garbage sack, obtained the garbage, and took the items to the soiled utility room. Staff member L washed her hands after placing the items in the proper containers in the soiled utility room. Staff member L did not remove her gloves when soiled and did not washed or sanitize her hands after providing care to resident #11. Staff member L stated the staff are to remove gloves after resident care, and before and after they enter a residents room. She stated she should have changed her gloves after she provided peri care to resident #11. 3. During an observation and interview on 9/14/21 at 2:40 p.m., staff members I and J assisted resident #14 off the toilet and to the bed with the use of a mechanical lift. Neither staff member sanitized the mechanical lift prior to use or after use. Staff member I stated the staff are supposed to clean the mechanical lift with the sanitizing wipes after each transfer. Staff member J stated the staff are supposed to clean and sanitize the mechanical lifts before and after use but she could not find the wipes to clean the lift after the transfer of resident #14. 4. During an interview on 9/15/21 at 12:06 p.m., staff member O stated the bathroom in resident #30's room had tiles missing from the flooring. She stated the floor had been that way for seven years and it had not been repaired. During an observation on 9/15/21 at 12:22 p.m., the bathroom flooring in resident #30's room had tiles missing around the toilet, with cement and old adhesive showing. The floor was a non-cleanable surface. 5. During an observation on 9/14/21 at 11:35 a.m., staff member Q entered resident #343's room to assess and redress her suprapubic catheter dressing. Staff member Q did not perform hand hygiene before entering resident #343's room, or before putting on gloves to dress the resident's wound. 6. During an observation on 9/14/21 at 2:19 p.m., staff member Q entered resident #8's room to provide wound care and change her dressing. Staff member Q did not perform hand hygiene before entering resident #8's room, before and after moving her, or when adjusting her bed. 7. During an observation on 9/14/21 at 2:36 p.m., staff member Q re-entered resident #8's room with wound care and dressing supplies. Staff member Q did not perform hand hygiene before entering resident #8's room, or before donning gloves, to assist with wound care. 8. During an observation on 9/14/21 at 2:56 p.m., staff member Q cleaned resident #8's wound. Staff member Q did not perform hand hygiene, or change his gloves after cleaning the wound, until prompted by staff member H. 9. During an interview on 9/15/21 at 11:30 a.m., staff member Q stated he had worked at the facility for over a year, and that he had one on one training, including return demonstration, with infection control. Staff member Q stated that staff member B taught one on one wound dressing and hand hygiene practices. Staff member Q stated he was trained to wash or sanitize his hands in the patient room before donning gloves, after touching the patient, and before re-donning gloves during wound care. Staff member Q stated, I try to wash my hands as often as I can. 10. During an interview on 9/16/21 at 11:55 a.m., staff member A stated the facility policy is to train staff on hand hygiene practices based on the guidelines from the WHO and Potter and Perry resources. A review of the facility's policy, Infection Prevention and Control Program, reflected, The World Health Organization (WHO) guidelines are followed for hand hygiene for all employees. Review of the WHO guidelines, Hand Hygiene: Why, How & When?, reflected, [use hand hygiene] Before touching a patient .Before assisting a patient in personal care activities: to move .Before dressing a wound .After removing any form of material offering protection ( .dressing, gauze .) .after other contacts with surfaces or inanimate objects .

Based on observation and interview, the facility staff failed to maintain sanitary practices while serving meals to the residents, for 2 (#s 16 and 00), and failed to dispose of some expired juice in the storage area, of 24 sampled and supplemental residents. Findings include: 1. During an observation on [DATE] at 12:20 p.m., 38 cans of 5.5-ounce prune juice were noted in the dry storage area. The cans remained in the dry storage on [DATE] at 7:30 a.m. The prune juice had expired [DATE]. During an interview on [DATE] at 7:20 a.m., staff member D stated, Whoever puts the groceries away is to check for outdated foods and alternate the groceries. Staff member D stated the prune juice was for a resident that passed away and had not been used for anyone else. 2. During an observation on [DATE] at 7:20 a.m., staff member D was serving resident food, and used the same spatula for hash browns and bacon while serving. Staff member D stated she should have used two different spatulas and obtained new spatulas for the rest of food service. 3. During an observation and interview on [DATE] at 9:15 a.m., staff member F took resident #16 and #00 room trays, and staff member F had to walk to the resident rooms with the trays. The silverware, on the room trays, was not covered, and it was placed on the top of the napkin. Staff member F stated, As far as I know the silverware just goes out like that, not covered. During an interview on [DATE] at 2:19 p.m., staff member J stated the silverware is never rolled up or covered on the room trays, and it just sits on top of the napkins on the tray. Staff member J stated she did not know if the facility knew how to roll the silverware up or cover it, like another facility she worked at had done. The silverware was not covered during transport from the kitchen to the residents who were served meals in their rooms, from [DATE] to [DATE]. 4. During an observation on [DATE] at 12:14 p.m., staff member S, who was working with resident food, was observed wearing gloves. Staff member S reached into the pocket of his shirt, and removed a marking pen. Staff member S then began marking plastic bags with the marking pen, then placing open cheese slices and meet slices into the bags, without changing his gloves or sanitizing his hands before touching the food again.

Based on observation, interview, and record review, the facility failed to ensure all expired medications, including stock medications, opened liquids, vaccines, and supplies, were removed from use and disposed of from the medication cart, and the medication and supply storage room, for 2 (#s 17 and 00) of 24 sampled and supplemental residents. This deficient practice created a risk for residents if they were to be given or use supplies or medications that were expired. Findings include: During an observation on 9/15/21 at 8:48 a.m., of a medication storage cart, the following was found: - One Imperial Med Plus 2.0 Vanilla 32oz container, opened, with no labeled open date; and, - One [MEDICATION(S)] Nasal Spray 1oz bottle for resident #17, exp. 6/21. During an interview on 9/15/21 at 8:49 a.m., staff member Q stated the nurses check the medication carts every Tuesday for expired medications when they get new medications in the facility. During an observation on 9/15/21 at 10:05 a.m., in a medication and supply storage room, the following expired medication, vaccine, and supplies were found: - One bottle of Geri Care Vitamin B6 100 mg tablets, 100 tablets, exp. 7/21, - One [NAME] 2 x 2 in [MEDICATION(S)] dressing for resident #00, exp. 6/21, - Three [MEDICATION(S)] vaccine 0.5 ml syringes, exp. 9/13/21, and - Six [NAME] 6 x 6 in [MEDICATION(S)] Foam Backing dressing, exp. 7/21. During an interview on 9/15/21 at 2:14 p.m., staff member H stated the medication storage room was checked every week by night shift staff, and that medications were disposed of by using an onsite drug buster within seven days. A review of the facility's policy, Destruction of Medications, reflected, Disposal of all drugs will occur within 72 hours of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and interview, a facility staff member failed to provide services to accepted standards of clinical practice for 1 resident (#36) when flushing a peripherally inserted catheter (PICC), of 20 sampled residents. Findings include: During an interview on 09/13/21 at 2:51 p.m., resident #36 stated, [Described staff member C] travel nurse has pushed [MEDICATION(S)] into my PICC line very quickly. She has been instructed by staff member B on the proper push of [MEDICATION(S)]. I reported it to the director of nursing and other nurses. During an interview on 09/16/21 at 9:10 a.m., staff member C stated, I worked in ICU, I was used to pushing (flushing) fast (through PICC line). She [resident #36] told me it was too fast and reported me. Reference: 1. According to [MEDICATION(S)] Plus Medical Encyclopedia, Peripherally inserted central catheter - flushing, . 8. Inject the saline slowly into the catheter by gently pushing on the plunger. Do a little, then stop, then do some more. Inject all the saline into the catheter. Do not force it . When flushing with [MEDICATION(S)], . 2. Flush slowly by injecting a little at a time, the same way you did the saline . https://medlineplus.gov; (Reviewed date 9/28/20)

Based on record review and interview, the facility failed to conduct timely gradual dose reductions (GDR's) for 1 (#30), when identified as a concern by the consulting pharmacist, of 20 sampled residents. This created risk for the resident due to the lack of follow up, and the extended timeline in which the GDR was not addressed. Findings include: Review of resident #30's medical record, titled: Consultants Pharmacist's Progress Note, subtitled: Includes the following Classifications: MRR, dated 6/1/2021 and 6/10/2021, showed: . A GDR attempt for [MEDICATION(S)] is due. A request was sent for the providers review. Review of resident #30's Consultants Pharmacist's Progress Note, subtitled: Includes the following Classifications: MRR, dated 7/1/2021 and 7/15/2021, showed: . No response was given for the GDR request sent on [MEDICATION(S)] in June 2021 . Review of resident #30's Consultants Pharmacist's Progress Note, subtitled: Includes the following Classifications: MRR, dated 8/1/2021 and 8/12/2021, showed: . No response was given for the GDR request sent on [MEDICATION(S)] in June 2021. Will send a repeat request in [DATE] . Review of resident #30's Consultants Pharmacist's Progress Note, subtitled: Includes the following Classifications: MRR, dated 9/1/2021 and 9/10/2021, showed: . GDR for [MEDICATION(S)]: Required yearly.No response given for request sent in June 2021. Request resent [DATE]. Review of the facility's document, titled: GDR's and other items, dated 8/29/2021, signed by NF1, showed: . I am recommending the facility implement a PIP on your GDR process on Monday morning at end of your meeting. Follow-up on pharmacy reports - there should never be a no response or declined without explanation written on the consults by pharmacy consultant. We need to make sure when we are rounding with physicians that these are addressed or they give adequate explanation on the GDR request or in their progress note. Review of resident #30's medical record document, with no title, showed on 9/16/21 at 8:54 a.m., GRADUAL DOSE REDUCTION TRACKING: Discontinued [MEDICATION(S)] 5mg. 9:21 a.m., spoke with office staff at [NF2's] office, Re: Pharmacy Consultant progress notes she has reviewed recently regarding GDR for [MEDICATION(S)]. During an interview on 9/16/21 at 10:10 a.m., staff member A stated, after a corporate audit, on 8/29/21, timely GDRs were identified as an issue. The facility educated the providers and continues to work on the concerns with the GDRs.

Based on observation, interview, and record review, the facility failed to implement person centered interventions for falls, appropriately assess the resident after a fall; failed to put individualized measures into place to prevent future falls, one of which resulted in a major injury, for 1 (#25) of 3 sampled residents. Findings Include: During an observation and interview on 3/2/21 at 7:50 a.m., staff member F stated resident #25 was found on the floor this morning, and nurses were doing hourly neuro checks because the fall was unwitnessed. Resident #25 was observed to have his left arm bandaged, and was sitting in a chair as the nurse handed him his medications. Resident #25 had a bedside table next to him, and the walker was on the other side of the table next to the window, out of reach. During an observation on 3/2/21 at 10:53 a.m., resident #25 was observed lying in bed on his right side facing the window, and no walker or wheelchair within reach. The bed was not in a low bed position, and the walker was in a corner. During an interview on 3/3/21 at 2:00 p.m., staff member F stated resident #25 was still not back from the hospital. The hospital had notified the facility resident #25 had a fractured coccyx. During an interview on 3/3/21 at 2:04 p.m., staff member E stated he had sent resident #25 to the emergency room , via ambulance, for a possible arm or [CONDITION(S)]. Staff member E stated the resident was having pain and could not get up from the fall. Staff member E stated resident #25 was found on the floor, on his side, approximately at 4:00 p.m., with a laceration to the forehead, and his pants were around his ankles. Staff member E stated nurses were to do an assessment and paperwork for falls right after treating the resident. During an interview on 3/3/21 at 3:24 p.m., staff members E and J stated resident #25 had brittle skin. Resident #25 would wander at various times throughout the day and night because his [MEDICATION(S)] levels spiked, and he would be confused. Staff member E stated he would give resident #25 water as he would be thirsty and to redirect him back to his room. Staff member J stated resident #25 would wander without an assistive device and forget how weak he was. During an interview on 3/4/21 at 7:21 a.m., staff member A stated resident #25 was not a wanderer right away upon admission. It was only because his [MEDICATION(S)] levels were getting progressively worse. During an interview on 3/4/21 at 8:39 a.m., staff member L stated resident #25 was still at the hospital with a broken coccyx. Staff member L stated nurses are expected to respond to falls and check the resident for injuries. After treating the resident, nurses are to complete notifications and documentation regarding the falls. Review of resident #25's Admission Fall Assessment on 12/16/20, showed for the questions: -Does the resident have a history of a fall or multiple falls? The facility answered, Yes Previous at home. -Does resident have an unsteady gait? The facility answered, Yes need walker for ambulation. Review of resident #25's fall incident documentation for the two falls that occurred on 3/2/21 showed: 1. First fall on 3/2/21 at 4:25 a.m. Incident Report: Documentation was not completed until 9:06 a.m. and showed the fall occurred at 4:25 p.m. [sic] The incident report showed resident #25 was observed on floor and sustained eight total skin tears to both arms with skin flaps that pulled over and were cleansed and treated with steri-strips and island dressings. Resident #25's blood pressure was noted as 95/62. The intervention was listed as offer assistance to the bathroom every 2 hours epically throughout the night as this seems to be the time he wanders more often. [sic] Assessment supporting intervention showed, Resident stated that he was trying to go to the bathroom and he leaned on the door and the door moved and he fell . Post Fall Assessment: No post fall assessment was completed. The Investigation Report for the fall showed: -Instability due to acute condition. The answer marked was no. -Internal risk factors, nothing was entered. -Property/Equipment Involved, marked as no. -Other causal Factors: Resident does sundown and wanders more in the evening and night. He has end stage liver disease, He is confused and is ambulatory. [sic] Root Cause Analysis for the fall showed: -What appears to be the initial root cause(s) of the fall? Hand-written in was, leaned on door -Describe initial interventions to prevent future falls Hand-written in was, Offer assistance to bathroom Q 2hrs - during evenings & nights. -Conclusion Hand-written in was, Will offer assistance to bathroom Q 2 hrs evening & nights. -Additional Care Plan/Nurse Aide Assignement [sic] Updates Hand-written in was, yes 9:12am 3-2-21 [sic] The Fall Scene Investigation showed: -Factors observed at time of fall: Resident lost their balance was noted. -Gait assist devices at time of fall: None was noted. -Medications given in last 8 hours prior to fall Diuretic and [MEDICATION(S)] were selected. -Did orthostatic BP's suggest the BP change contributed to the fall? No answer was marked. -Blood sugar check is required for diabetic resident. Was residents blood sugar significant? and Does recent Hgb show evidence of [CONDITION(S)]? No answer was marked for either. 2. Fall on 3/2/21 at 4:00 p.m., 12 hours after the first fall. Incident Report: Documentation was completed at 5:20 p.m., with the fall occurring at 4:00 p.m. The report showed resident #25 was found on his right side and turned over to complete an assessment. The resident was found with a forehead laceration and bruise and skin tear to the left hand, and a left knee laceration and could not fully extend his right leg. Resident #25's blood pressure was noted as 89/51. Resident #25 was sent to the emergency room for further evaluation. A Post Fall Assessment was completed on 3/2/21 at 5:22 p.m. and showed: -Does the resident have any of the following diagnosis or conditions? Answer marked, Yes Chronic condition causing instability incontinence was noted. -Is resident receiving medications which might contribute to possible falls? Answer marked, Yes Diuretic(s): [MEDICATION(S)] and [MEDICATION(S)]. -Does the resident exhibit signs of acute confusion (delirium)? Answer marked as, Yes with Resident can become confused when his [MEDICATION(S)] levels are high noted. -Does the resident have a history of a fall or multiple falls? Yes with Resident had fall previously in the day noted. Investigation Report: The 2nd fall did not have an Incident Investigation form completed. The Root Cause Analysis questions showed: -What appears to be the intial [sic] root causes(s) of the fall? Hand-written in was, pants around ankles & he was trying to ambulate. The root cause of the resident attempting to use the bathroom on his own was not noted in this area. -Describe initial interventions to prevent further falls Hand-written in was, would place on 15 minute checks if not have gone to ER. After D/C to hospital Room was rearranged for safety. therapy to reasses after return. Medication reconciliation prior to return from [physician]. [sic] -Conclusion Hand-written in was, See above -Additional Care Plan/Nurse Aide Assignment Updates Hand-written in was, Will update [illegible word] upon return The Fall Scene Investigation for resident #25 showed for the questions: -Factors observed at time of fall: Resident lost their balance was marked. -Gait Assist Devices at time of fall: none was marked. -Medications given in last 8 hours prior to fall Diuretic and [MEDICATION(S)] were marked. -Were temperature, pulse, respirations and/or O2 sat out of normal range for this resident? Yes was marked. -Did orthostatic BPs suggest the BP change contributed to the fall? No answer was marked. -Blood sugar check is required for diabetic resident. Was resident's blood sugar significant? No answer was marked. -Does recent Hgb show evidence of [CONDITION(S)]? Yes was marked. Review of the CNA assignment for 3/1/21 showed resident #25 was to have, Check and changed every 2 hours and as needed Assist of 1. This was prior to both the resident's falls and not on the care plan. Review of resident #25's physician orders showed the resident had diagnoses of [CONDITION(S)] [CONDITION(S)], end stage renal disease, hepatic [CONDITION(S)], and Type 2 diabetes. Review of resident #25's Care Plan showed: - A care area entered on 12/16/20 for a Self Care Deficit related to previous falls at home and his diagnoses. The intervention was to Monitor impulsive behaviors or actions indicative or altered judgements. [sic] The care plan did not show how staff were to monitor the resident, or what to do if impulsive behaviors/actions, or altered judgements occurred. - Care areas were entered on 2/24/21 for Alteration in Thought processes, Increasing Forgetfulness .fluctuating awareness .need for 24 hour care and supervision. The interventions listed were not specific to the residents' current needs and did not show how to assist the resident when he was having a change in cognition/cognition. - The care area entered as, Trauma-Falls injury had an intervention of placing items near the resident and to Encourage [resident #25] to call for assist using his call light prior to getting up or attempting to ambulate independently. This did not show any assistive devices or staff assistance needed. The plan did not note the staff may need to anticipate the resident's needs related to safety/fall prevention. -On the last pages of resident #25's care plan, on 1/2/21, an entry of FWW was documented without a specific care area or information for when it was to be used. Review of the 3/2/21 hospitalization records for resident #25 showed: -Findings: Stomach and bowel: There is large amount of stool present in the rectosigmoid colon, -Bones/joints: There is a fracture of the junction of the sacrococcygeal spine with 5 mm of anterior displacement of the coccyx. - [MEDICATION(S)] levels showed as abnormal level of 117 umol/L which is high. Review of the facility policy, Fall Assessment and Prevention Protocol, last updated April 2020 showed: - If/when a resident experiences a fall, root cause analysis will be conducted to assist in planning appropriate evidence-based interventions to prevent further falls, - A Fall Assessment will be conducted . as a reactive measure when falls occur, - A new fall assessment will also be completed after each fall, quarterly, and upon any significant change in a resident condition, - .provide immediate appropriate intervention. Assess the scene and begin the Fall Scene Investigation Report, a root cause analysis tool for falls that looks at internal, environmental and operations/systemic conditions that may have contributed to/been responsible for the fall, - Update the resident care plan in ECS with the appropriate intervention(s) to keep resident safe until reviewed by interdisciplinary team the following business day, - Add any new interventions to the C.N.A. assignment sheet and to the 24-hour report to communicate any new resident needs.

Based on observation, interview, and record review, the facility failed to implement a comprehensive care plan to include measurable and personalized interventions for falls for 1 (#25) of 1 sampled resident. Findings include: During an observation and interview on 3/2/21 at 8:02 a.m., resident #25 was sitting in a chair with a bedside table directly in front of him. A walker was on the other side of the table next to the window, out of reach. Resident #25 was noted to have multiple white bandages covering both arms, from the back of his hand, to his upper arm. Resident #25 stated he fell trying to go to the bathroom. During an interview on 3/3/21 at 1:57 p.m., staff member K stated resident #25 was sent to the hospital for a fall the day before. During an interview on 3/3/21 at 3:24 p.m., staff members E and J stated resident #25 had brittle skin. Resident #25 would wander at various times throughout the day and night because his [MEDICATION(S)] levels would spike and he would be confused. Staff member E stated he would give water to resident #25 as he would be thirsty, and to redirect him back to his room. Staff member J stated resident #25 would wander without an assistive device and forget how weak he was. Review of resident #25's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #25's Care Plan showed: -A care area was entered on the plan on 12/16/20 for a Self Care Deficit, related to previous falls at home, and the resident's diagnoses. The intervention was to Monitor impulsive behaviors or actions indicative or altered judgements. [sic] The care plan failed to show how the facility monitored the resident, or what staff should do related to the cocnerns noted. -Care areas were entered on the plan on 2/24/21 for Alteration in Thought processes, Increasing Forgetfulness .fluctuating awareness .need for 24 hour care and supervision. The interventions listed were not specific to the residents' current needs/risks and it did not show how to assist the resident when he was having a change in cognition. -The care area entered on the plan as, Trauma-Falls injury had an intervention of placing items near the resident and to Encourage [resident #25] to call for assist using his call light prior to getting up or attempting to ambulate independently. This did not show any assistive devices for the resident, or the staff assistance needed, related to the walker or cognition fluctuation. -On the last pages of resident #25's care plan, on 1/2/21, an entry of FWW was made without a specific care area or information for when it was needed to be used. Record review of resident #25's fall documentation showed he had two falls on 3/2/2021, within 12 hours of each other, one with a significant injury, and between the two falls multiple skin injuries, and a head injury. Refer to F689 for details related to falls.

Based on observation, interview, and record review, the facility failed to ensure staff wore adequate personal protective equipment before entering a transmission based precautions room; failed to ensure staff performed appropriate hand hygiene after doffing personal protective equipment and exiting a transmission based precautions room for 1 (#149) of 3 sampled residents and failed to ensure staff donned gloves before entering a transmission based precautions room for 1 (#148) of 3 sampled residents. Findings include: During an observation on 3/1/21 at 10:45 a.m., transmission based precautions signage for Contact Precautions, Droplet Precautions, and Airborne Precautions was posted on the doors of rooms [ROOM NUMBER]. During an observation on 3/1/21 at 11:55 a.m., staff member G prepared to exit resident #149's room. Staff member G removed the gown, gloves, and N95 mask in the room, then exited the room. Staff member G opened the top drawer of the bin/container for PPE, located outside resident #149's room, and donned a surgical mask. Staff member G walked down the hallway to enter another resident's room, but was unable to enter due to a nurse being in the room. Staff member G then exited the hallway. Staff member G did not wear a faceshield before he entered resident #149's room nor did he perform hand hygiene after he doffed the PPE in resident #149's room. During an interview on 3/2/21 at 2:17 p.m., staff member G stated no goggles were in the bin outside resident #149's room, but he found the N95 respirator, gloves, and the gown that were donned before he entered. Staff member G stated he should have sanitized his hands, but knew he did not, when he doffed the PPE and after he left the room. Staff member G stated he took an online course on donning and doffing PPE in November 2020, but no return demonstration was performed at the facility for this training. During an interview on 3/2/21 at 2:49 p.m., staff member E stated an online class (Onboarding) and inservice were done on PPE donning and doffing. No return demonstration was performed after training. During an observation on 3/3/21 at 8:29 a.m., staff member H donned a N95 mask, faceshield, and gown in the doorway of resident #148's room, before she entered and closed the door. Staff member H did not have gloves on before she entered the room. During an interview on 3/3/21 at 8:34 a.m., staff member H stated gloves were donned, from her scrub top pocket, after she closed the door to resident #148's room. Staff member H stated donning and doffing PPE was an online training completed in November of 2020. No return demonstration was performed. During an interview on 3/4/21 at 8:40 a.m., staff member B stated staff were monitored randomly and rounds were done to watch proper PPE donning and doffing. During an interview on 3/4/21 at 8:46 a.m., staff member A stated no return demonstration was done after PPE training. Staff member A stated they (administration) only correct, if on random audits they (staff) do something wrong, then they (staff) are shown how to do it correctly. Staff member A stated staff are then asked to do a re-demonstration to show they can do it correctly. A review of the facility's policy titled, Coronavirus (COVID-19) - Prevention, Identification and Response Plan, last revised 8/18/20, showed: -16. Ensure employees clean their hands according to CDC guidelines, including before and after contact with residents, after contact with contaminated surfaces or equipment, and after removing personal protective equipment (PPE), -18. Re-educate staff on Standard and Transmission-Based Precautions and ensure they are following them consistently. c. See Contact Precautions Sign . A review of the Center for Disease Control and Prevention signage titled, Contact Precautions, posted on the transmission based precautions rooms, showed: - EVERYONE MUST: Clean their hands, including before entering and when leaving the room, -PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry . References: https://www.cdc.gov/infectioncontrol/pdf/strive/PPE104-508.pdf .In order to improve practice it is important that the correct use of PPE be rigorously and consistently applied -A recent study demonstrated that only half of healthcare personnel removed PPE correctly under normal conditions -Audits can provide immediate feedback and identify gaps in practice (Zellmer C et al., AJIC, 2015) -What does the audit process involve? -Starts with competency based training -Demonstration of selection of appropriate PPE -Ability to locate PPE -Demonstration of correct donning and doffing -Trainee demonstration of correct donning and doffing -Regular audits for adherence .

Based on observation, interview, and record review, the facility failed to prevent the development of two avoidable Stage II pressure ulcers which caused pain for a resident, and staff failed to ensure the resident's pain was managed during pressure ulcer care, for 1 (#48); failed to prevent the development of an avoidable Stage II pressure ulcers for 1 (#49); and failed to sufficiently identify a resident's risk for developing pressure ulcers, implement appropriate interventions, notify the physician and obtain timely treatment orders, and document the pressure ulcers as needed, for two avoidable Stage II Pressure Ulcers, one to the right lower buttock, and one on the resident's right anterior foot, for 1 (#29) of 22 sampled and supplemental residents. Findings include: 1. During an observation and interview on 1/6/20 at 1:40 p.m., resident #48 was lying quietly in bed with the head of the bed elevated. Resident #48 stated there were two pressure ulcers on his tailbone that caused him pain and the pressure ulcers were from here (facility). During an interview on 1/8/20 at 9:51 a.m., staff member F stated resident #48 developed his pressure ulcers at the facility. Staff member F stated, at times resident #48 could be noncompliant with re-positioning, especially after hospice discharged him. Staff member F stated since his re-admission to hospice care, he has been more compliant, getting up more, and more willing to re-position. Staff member F stated staff had requested the resident re-position every hour. Staff member F stated staff educated resident #48 on the risks of not re-positioning and encouraged him to move. During an interview on 1/8/20 at 10:04 a.m., staff member K stated resident #48 allowed the staff to re-position him, every hour or two, by moving pillows on the sides of his butt. Staff member K stated resident #48 moved to his chair during the day, and requested to lie down in bed after lunch, but mostly he was repositioned with the pillows in bed. During an observation on 1/8/20 at 1:26 p.m., resident #48 was lying flat on his back in bed. Staff member F and staff member G entered resident #48's room to perform a wound dressing change. Resident #48 had two opened areas on his left buttocks, approximately 1 cm x 1 cm each in size and dark pink in color. While staff member G cleansed resident #48's wounds, the resident flinched during the procedure. Staff member G asked resident #48 if that hurt and resident #48 stated yes. Neither staff member G, nor staff member F, offered resident #48 pain medication, or to stop the procedure, due to pain. After the wound dressing change was performed, resident #48 remained lying flat on his back in bed. During an interview on 1/8/20 at 1:35 p.m., staff member G stated she had been the wound care nurse for the past three years and had not been trained in wound care specifically. Staff member G stated the facility has problems with wound care and need to have a system in place to better address the handling of wound care supplies. During an observation and interview on 1/9/20 at 10:37 a.m., resident #48 was lying in bed on his back. Resident # 48 stated he could not recall staff ever asking him about getting pain medication before a dressing change on his wounds. Review of resident #48's Admission MDS, with an ARD of 2/8/17, showed under Section M, Skin Conditions, one Stage I pressure ulcer. Review of resident #48's Significant Change MDS, with an ARD of 9/2/19, showed under Section M, Skin Conditions, two Stage II pressure ulcers that were not present upon admission or reentry. Review of resident #48's Quarterly MDS, with an ARD of 12/1/19, showed under Section M, Skin Conditions, two Stage II pressure ulcers that were not present upon admission or reentry. Review of resident #48's Weekly Skin Assessment notes, dated [DATE], showed: -Skin Problems: reddened, Excoriation, -Pressure Ulcer: Partial thickness loss of skin layers that presents as an abrasion or blister (Pressure Stg. 2), -Location: bilateral buttocks -Length: R 10 cm -Width: 5.0 cm -Length: L 8.0 cm -Width: 5.0 cm -Tissue Type: [MEDICATION NAME] tissue -Wound Tissue: Reddened -Drainage: light exudate -Surrounding tissue: Pink -Healing Progress: New Area -Skin Treatment: Receives application of dressing. Review of resident #48's Care Plan, updated 9/3/19, showed: - Assess skin status, - assess nutrition stat., - keep MD informed, - administer medications as ordered, - remove shoe and socks after dinner, - elevate lower extremities and rest feet on mat placed over foot rests, - apply [MEDICAL CONDITION] properly, - monitor for areas of pressure from [MEDICAL CONDITION], - wound nurse to measure and monitor healing weekly, - keep head of bed at 30 degree or lower, - resident to be placed in bed x one on day shift and to be placed in bed or position chair with head at 30 degrees or lower on evening shift to off load pressure, - Reposition every 2 hours while in bed, - has ROHO cushion and geo mattress. Review of resident #48's Care Plan, updated 12/3/19 showed one change under the Approach section, Reposition every one hour while in bed. Review of the resident #48's TAR, dated 8/19, with an entry date of 8/11/19, showed: -SKIN TREATMENT: Apply coccyx or regular duoderm to bilateral buttocks on excoriation area 1 x wk. Saturday AM (until resolved). -SKIN TREATMENT: Monitor coccyx or regular duoderm to bilateral buttocks on excoriation area twice a day AM PM (until resolved). -No changes had been made to the treatment or the monitor orders since initiation on 8/11/19. Review of the facility Skin Care Management policy, with a revised date of 11/19, showed: - 6. When a resident is admitted with or develops a pressure injury. - b. Comprehensive assessment of pain and implementation of pain control measures prior to treatment is the first priority in wound care management. 2. During an observation and interview on 1/9/20 at 3:29 p.m., resident #29 was sitting on a black cushion in his wheelchair and stated he had a pressure ulcer on his bottom. Resident #29 declined an observation of the wound. Resident #29 stated the wound does not hurt him, and he is not sure if it is improving because he cannot see it. Resident #29 stated the nurses say it looked good and put a big band aid on it a couple of times. During an interview on 1/9/20 at 5:41 p.m., staff member C stated resident #29's pressure ulcer was almost closed. Staff member C stated resident #29 developed one pressure ulcer from wearing tight jeans, and another pressure ulcer from tying his shoes too tight to his feet. Staff member C stated that resident #29's pressure ulcer to the right lower buttock was facility acquired and was avoidable. Staff member C stated resident #29 discharged from the facility with them in July 2019, then came back to the facility a few days later, as a new admission. Staff member C stated that resident #29 cannot walk on his own but can stand and pivot for transfers. Staff member C stated resident #29's pressure sores on his toes were caused from wearing tight shoes, tied tightly. During an interview on 1/9/20 at 5:41 p.m., staff member G stated resident #29 has been better about skin care as he was not very compliant six months ago. Staff member G stated that resident #29's skin care was monitored on the treatment record, and by her (Staff member G), once a week for measurements. Staff member G stated that resident #29 sleeps in a recliner, and his wheelchair cushion is moved to it at night, and resident #29's pressure ulcer (on his bottom) had closed and reopened in the last six months. Staff member G stated on 9/6/19 resident #29 had a pressure sore reopen. Staff member G stated resident #29's current pressure ulcer care consisted of duoderm and foam dressings. Review of resident #29's skin assessment notes showed the following: - On 6/10/19, resident #29's right lower buttock dressing was intact, a small red area was noted on the left coccyx, and the right foot dorsal area was red in color. No wound staging was completed at this time. - On 6/15/19, a new area was noted to the right lower buttock measured 2 cm long, 1 cm wide, and less than .1 cm deep. The skin treatment was noted as it was cleaned, and a duoderm had been applied. - On 6/29/19, resident #29's right lower buttock was staged as, Partial thickness loss of skin layers that presents as an abrasion or blister (Pressure Stage 2). - On 7/6/19, resident #29's Pressure Ulcer to the right buttock was noted to be 2 cm long by 1 cm wide with light exudate drainage. - On 7/14/19, resident #29's right lower buttock Stage II Pressure Ulcer was measured 2 cm long, 1 cm wide, and less that .1 cm deep with light exudate. It was noted to be improving and shallower. The staff noted to had changed duoderm to right buttocks. - On [DATE] re-admit assessment it was noted resident #29 had skin conditions to his right lower buttock 2 x 2 cm diam soft scab with superficial layers missing, red to perimeter, dsg applied. (sic) Resident #29 was also noted to of had a red area on his top right foot, and a red area to his coccyx. - On 7/27/19 resident #29 was noted to of had, Partial thickness loss of skin layers that presents as an abrasion or blister (Pressure stg 2). The location was his right lower buttock that was noted to be 2 cm long and 2 cm wide the tissue was [MEDICATION NAME] with soft clear scab with light exudate and surrounding tissue was a, red perimeter dark pink buttock re admit. - On [DATE], resident #29's right lower Pressure Ulcer is noted to be 2 cm long and 1.5 cm wide with light exudate drainage. - On 8/29/19, resident #29's right lower Pressure Ulcer is noted to be 2 cm long by 1.5 cm wide and .1 cm deep with light exudate drainage. - On 11/4/19, resident #29's right lower buttock pressure sore is noted to be closed. Resident #29's right anterior foot noted to have worsened to a Stage II Pressure Ulcer that measured 2 cm long by 2 cm wide with light exudate. - On 12/11/19, resident #29's right buttock is noted to a Stage II Pressure Ulcer. It measured .25 cm long by .25 cm wide. - On [DATE], it is noted that resident #29's right lower buttock remains pink foam dressing to area. - On 1/08/19, resident #29's right lower buttock was noted to be closed. The skin treatment was noted as, Has pressure relieving device for chair. Receives application of dressings (with or without topical medications (other than feet). - Resident #29 had an avoidable Stage II Pressure Ulcer that healed and reopened to his right lower buttocks and another avoidable Stage II Pressure Ulcer to his right anterior foot. Review of resident #29's physician orders, dated [DATE], showed the following: -Skin treatment: change foam dressing to right gluteal fold every three days, -Skin treatment: check foam dressing to right gluteal fold every shift, -Skin treatment: Apply skin assessment on bath day one time per week, -Skin treatment: Apply calmo to inner buttocks as needed. -No other skin orders were noted for the most recent reopening of resident #29's right lower buttock pressure sore or right anterior foot. Review of resident #29's Braden Scale assessments, dated 6/8/19, [DATE], 8/8/19, 8/15/19, [DATE], 9/6/19, and 12/5/19, do not show if the resident was at risk, or not at risk, for developing a Pressure Ulcer. Review of resident #29's Treatment record, from June 2019 to January 2020, show no treatments to the right anterior foot. Review of resident #29's care plan showed the following: -An identified problem of impaired skin integrity and non-compliance, -An approach for skin integrity impairment, dated 10/25/19 as, Nurses--Assess skin status, measure and document weekly, Follow medical plan for treatment, monitor fit of pants, assist to provide and encourage resident to wear loose pants, Equalizer cushion in chair to off load pressure, Direct supply mattress, assist and encourage reposition every shift. Refer to dietician, assess and provide proper fitting foot wear. (sic) -A goal on 11/12/19 of no breakdown of area. -No revisions had been made to the care plan after the reopening of the right lower buttock Pressure Ulcer on 12/11/19. The facility failed to adequately identify resident #29's risk for developing pressure ulcers, implement appropriate interventions, prevent an avoidable Stage II Pressure Ulcer to resident #29's right lower buttocks, and re-evaluate the effectiveness of interventions and revise them upon the reoccurrence of a Stage II Pressure Ulcer to the right lower buttocks. The facility, also failed to prevent an avoidable Stage II Pressure Ulcer to resident #29's right anterior foot, re-evaluate the effectiveness of interventions, revise interventions, obtain physician orders [REDACTED].#29's right anterior foot, and properly document the treatments received on the treatment record. 3. During an interview on 1/9/20 at 3:29 p.m., staff member N said she was monitoring the dressing on resident #49's great toe, although she said she had not seen the wound. She said the resident was (residing) on the East wing when the wound developed. During an interview on 1/9/20 at 3:33 p.m., resident #49 said he had a sore on his big toe. He said his sister looked at his toe after he told her it hurt. The resident said his sister put a band-aid on his toe after she looked at it. Resident #49 said his sister told the nurse about his big toe. The resident said the nurse changed the bandage on his big toe every couple of days. During an interview on 1/9/20 at 3:45 p.m., staff member C said resident #49 had told his sister his toe was hurting. She said the resident's sister took his boot and sock off, and saw he had a reddened area on his great toe, and she reported this to the nurse on duty on [DATE]. Review of resident #49's nursing progress notes showed a sore had appeared on his left great toe on [DATE]. A nursing note, dated 1/6/20, showed it was assessed by staff member C and staff member G and was determined to be a Stage II pressure ulcer. The physician was notified, and orders were received for a dressing and multiplex to the (L) great toe, and to change it every three days. Review of resident #49's care plan showed it was updated on 1/5/20 to include: -Problem: Tissue Integrity Impairment -Related to: Immobility, foot contracture -Manifested by: PI on left big toe -Goal: Potential for tissue injuries will be minimized and treated as per MD orders. -Nurses: Assess skin status on shower day. Keep MD informed. Follow medical plan for treatment. Refer to podiatrist for appropriated foot way (sic). Relieve pressure when in bed and with foam dressing. Keep top cover loose over feet. Wound nurse to monitor weekly.

Based on observation, interview, and record review, the facility failed to provide supervision and assistance to residents with identified swallowing deficits, and who were at risk for aspiration, for 4 (#s 8, 14, 17, and 44); failed to assess, provide the necessary assistance, and implement interventions to prevent aspiration risk, for a resident who was at risk for aspiration, for 1 (#14); and the staff failed to notify the nurse when a resident began to cough or gurgle while consuming meals or fluids, for 2 (#s 8 and 14); and failed to use a gait belt during a transfer for 1 (#29) of 24 sampled residents. Due to the concerns identified with resident #14, an Immediate Jeopardy was announced, and an extended survey was completed. Immediate Jeopardy: An Immediate Jeopardy situation was announced on 5/1/19 at 12:41 p.m., with the facility Administrator present. The Immediate Jeopardy situation was related to F689 - Freedom of Accidents, Hazards, and Supervision, for resident #14. The resident was identified to be a high risk for aspiration, and the resident had a modified diet. The resident was to be cued, assisted, and monitored at meals, but was not. The resident had a choking and coughing event during a meal, and was unassisted during the event, and after was not assessed sufficiently, and the resident had a rapid decline and passed away. The Immediate Jeopardy was cited at the Severity and Scope of a J, and upon removal of the immediacy of the safety risks, would be lowered to a G. The facility provided a plan to remove the immediacy, which was accepted by State Survey Agency on 5/2/19 at 2:31 p.m. Findings include: 1. During an observation and interview on 4/29/19 at 12:20 p.m., resident #14 had a ground texture meal, and two clear plastic cups of thickened liquids. He consumed one drink very quickly and had started on the second cup of thickened liquids, in between bites of his dessert. At 12:34 p.m., resident #14 was observed with a very moist cough. There were two CNAs, and the nurse, in the dining room area. The two CNAs were feeding other residents, not facing in resident #14's direction. The resident's coughing continued. No staff responded to resident #14 while he was coughing. The coughing then turned into gurgling sound the resident emitted. Staff continued to not approach the resident. At this time, resident #14 pulled his oxygen cannula out of his nose. The cannula hung from his left ear. No staff responded to resident #14 to reapply his oxygen cannula. Resident #14's lips were observed to be bluish purple in color. Resident #14 continued to cough and gurgle. At 12:41 p.m., staff member D came over to resident #14 and stated to him by name, Put down the glass and cough. Staff member D then walked over to Staff member Q, spoke something to her, and came back to resident #14. Staff member D then switched resident #14 from his oxygen concentrator to his portable oxygen tank. Staff member D wheeled resident #14 out of the dining room, and down the hallway into his room. Resident #14 was visibly struggling to breath, with rapid shallow breaths and gurgling from his airway. The use of the resident's accessory muscles was noticeable. Staff member D started a nebulizer treatment on 4/29/19 at 12:47 p.m. Staff member D had not performed any suctioning to resident #14. Staff member D stated There is no order to suction. He didn't want that. His guardian didn't want that. Resident #14's status was not improving with the nebulizer treatment. Resident #14 was observed to be reclined back in the wheel chair at that time. Staff member D stated she had checked the resident's oxygen level this morning, and it was 92% on 3 liters. Staff member D stated she had not yet checked resident #14's oxygen level, and she had sent the CNA to get the pulse oximeter. Staff member D placed the oximeter on resident #14's finger, and the oxygen saturation level was 65%. Resident #14's oxygen had been turned up to five liters per minute, and he was still receiving the nebulizer treatment, when the oxygen level was taken. Staff member D stated the resident hadn't improved with the nebulizer treatment, and she went to call the physician on 4/29/19 at 12:53 p.m. Staff member D was not able to speak to the physician, but spoke the physician's nurse. After speaking with the physician's nurse, staff member D walked back down to the resident #14's room, and the resident was still up in his wheel chair, and observed to have rapid, shallow breaths, and the gurgling sound he made had increased. Resident #14 continued to decline with his respiratory status. During an interview on 4/30/19 at 11:12 a.m., staff member M stated, We come in before we start our shift and review the CNA assignment sheet. If a resident has to have help with eating, we know the residents are a choking risk, because of the puree texture and thick liquids. So, we watch them. We keep an eye on them when they are eating. If they cannot feed themselves, depending on which resident it is, we do overhand and cueing. Once you get them started they can finish. With (resident #14), he was more of a supervision and a cue. We would cue him to eat and remind him to take smaller bites with his liquids. He had thickened liquids. He usually did really well. I never saw a problem with it. The only thing I saw a problem with is, he would take more than one bite at a time, before his mouth was empty. It had never happened to me that a resident was choking like resident #14. I think he should have had one drink at a time. There are some residents we do not give the drink to first, because then they do not eat as well, like (resident #17). We have her eat part of her meal so she will eat more of her food. (Resident #17) is a choking risk. I think we could have done that with (resident #14) instead of letting him have his liquids all at once. We need to have our residents who need assistance in one area so that we have all our aides in one place with them .We normally have one CNA to assist at the assist table. All residents that require assistance are at that table. I think they should have at least two CNAs at that table. The nurse is there but she has her duties to do, and she cannot always be there. During an interview on 4/30/19 at 10:21 a.m., staff member B stated if resident #14 did have an episode of aspiration on 4/22/19, it would be documented in the nursing notes. During an interview on 4/30/19 at 11:15 a.m., NF2 stated it had been over a year or two since she has worked with resident #14. NF2 stated she thought the resident had a few hospitalization s since then. NF2 stated, Yes, he is an aspiration risk. He has had several down-grades in meals due to his risk of aspiration. He was cognitively unable to participate in the speech therapy exercises, so we were unable to stop the progression. NF2 stated she would expect to see an assisted dining environment, nectar thickened liquids, a mechanical soft diet, and supervision with cueing, for someone who was at risk for aspiration. NF2 stated resident #14 was down-graded again to take away bread, because he was still having choking episodes. NF2 stated, (Resident #14) frequently coughed and choked during meals. He was never 100% percent safe or free of aspiration, so he was moved to the assisted dining room for assistance and closer supervision. NF2 stated, Some days (Resident #14) did need one-to-one (dedicated supervision of one person) with meals. NF2 stated she was unaware of the suspected aspiration event on 4/22/19, and she had not received any new orders to evaluate resident #14. NF2 stated, if I would have known about the incident, I would have downgraded the diet until I got in and got an speech therapy order for speech to eval. During an interview on 5/2/19 at 10:27 a.m., Staff member D stated, We wait to get the records from the speech therapist. We don't get her notes or records, and I am not sure where they go. I am not sure if her records get on the care plan, but the actual diet change gets on the care plan. Usually she (speech therapist) will watch them eat, and when I am here she will come and say what her record is going to be. She tells us, and then we don't actually see the order until it goes to the resident's doctor. The speech therapist will tell us if a resident needs to have supervision with their eating. It is overall supervision with intake, and if the resident is taking liquids without any signs of choking. The high aspiration risk residents would need close supervision, so we would need to have enough staff available. During an interview on 5/2/19 at 9:47 a.m., staff member B stated We assumed the resident aspirated on 4/22/19 and Resident #14 had a mechanical soft diet and nectar thickened liquids as of (MONTH) (YEAR). Staff member B stated, the resident needed supervision and more cueing. Staff member B stated, resident #14 was identified for as needed supervision ever since the assisted dining room was opened. She stated, if he needed assistance, I would not have left him alone. Staff member B stated the MDS coding of 3/2 meant resident #14 should not have be left alone, and that he needed meal assistance from staff. During an interview on 5/2/19 at 10:27 a.m., with staff member D, the day (resident #14's name) went into respiratory distress, staff member D stated, I called staff member B, and she told me that she was busy getting reports ready for the survey team and she couldn't come to help me. She stated, I didn't say (resident #14) was in respiratory distress, I just told her I have a crisis situation right now, and she said she couldn't come then. Staff member B didn't tell me to call someone else, I yelled for help to the other nurse, and staff member P and B just continued into another resident's room. Staff member B never went to help, but I yelled, and told (staff member P) I needed CNAs right away, and they stayed in the dining room while I took (Resident #14), to his room. Right after that, when I got him in his room, and got his oxygen plugged in, the CNA from West came in. I got his nebulizer machine and called the doctor. I verified again that the guardian didn't want suctioning. I think we are lazy in our documentation, because we are running short staffed, and I am here 10-12 hours everyday. I work even though I am scheduled for eight hours. If the guardian had not said no suction, I would have had the CNA get the crash cart or the nurse, and I would have suctioned him. I don't think the nebulizer treatment helped him. The treatments hadn't been affective prior to (Resident #14) went on comfort care. The first time the treatments helped. I had already given him a nebulizer treatment. I think his respiratory distress was due to a death rattle. He did have a quiet rattle. I think him chugging his second glass of liquid set (Resident #14) off (exacerbated event). He had some congestion the day before, but the nebulizer quieted the congestion that day. If we would have known they are going to need suctioning more than just at the last minute, we would have had that available ahead of time. If there would have been more staff in the dining room to assist with supervision, it would have been better. Review of the Care Area Assessment, from resident #14's Significant Change MDS, with an ARD of 2/21/19, showed OVERALL STATUS CHANGE: decline in activities of daily living some decline has been noted in the residents eating function. He has been observed to be feeding himself less, thus has required more physical assistance and cueing from the CNAs. We will cont. to monitor. this change and update CNA assign. sheet and care plan as indicated. Review of resident #14's Care Plan lacked documentation of the interventions from the Care Area Assessment, which showed the resident had required more physical assistance and cueing from the CNAs, with eating. Review of resident #14's CNA Assignment Sheet, dated 4/29/19, showed Mechanically/nectar thick liquids, AE at meals of scoop dishes, cues to take bites. Offer fluids and snacks. Monitor/Report Meal (sic). The CNA assignment sheet failed to show resident #14 required supervision and cuing from the staff. Review of resident #14's ADL 10-day Tracker form, dated 4/26/19 through 4/28/19, showed the resident was a 3/2 for eating. The summary of code for 2, which showed the amount of staff assistance that was required during the activity, showed 2-ONE PERSON physical assist. The summary codes of self performance on the ADL 10-day Tracker form showed 3 represented resident #14 was extensive assistance-if resident performed part of the activity . 2. During an observation on 4/30/19 at 12:45 p.m., four residents were observed to require total meal assistance. There was one staff member that sat in between two residents and provided meal assistance. The other staff member sat in between the other two residents that required total meal assistance. Resident #17 had an altered diet, and was not being supervised, as staff were assisting the other residents. Resident #17 who had not been supervised, was holding a large plastic cup with a sip lid on it. Resident #17 continued to take bites of her meal, and the cup began to tip sideways in her hand, causing the contents to gradually spill out all over the resident's lap, and the floor, during the lunch meal. Resident #17's trousers, and the seat of the dining chair, were saturated from the contents of the cup. The spill was not discovered until the end of the meal when staff went to take her away from the table. No cueing or assistance was offered to resident #17 by staff during the meal. A review of a list of residents, given to the surveyor and written by staff member A, showed who was designated as needing required supervision and meal assistance, and it was dated 4/30/19. It showed resident #17 was to receive supervision and meal assistance. 3. During an observation on 4/30/19 at 12:53 p.m., resident #8 was being assisted at the end of the table. She began coughing after receiving a spoonful of food from staff member O. Resident #8 continued to cough intermittently, removed her oxygen, and blew her nose in between coughs. Resident #8's lips were observed to be bluish purple. Staff member O stated, Could you please take resident #8 back, she is coughing and done eating. Staff member M took the resident back down to her room and assisted her to bed. Resident #8's head of the bed was flat. Resident #8 was not assessed for the risk of aspiration after the coughing in the dining room, and staff M and O did not notify the nurse of the coughing, so the resident could be monitored for a risk of aspiration. During an observation on 5/1/19 at 8:47 a.m., resident #8 received her tray at 8:14 a.m. She was observed to have eaten a few bites of her breakfast. Resident #8 had not received supervision or cueing from staff sitting at the table with her. The staff had not spoken to resident #8 since her meal tray was set up. Resident #8 was very pale in color, and her oxygen was noted under her chin, not in her nares. None of the staff present noticed resident #8 did not have her oxygen in her nares, and they did not assist her to replace the oxygen. The review of the list of residents who required supervision and meal assistance, dated 4/30/19, showed resident #8 was to receive supervision and meal assistance, and was at risk for aspiration. 4. During an observation on 5/1/19 at 12:05 p.m., staff member K was serving lunch to residents in the independent dining room. Staff member K was in and out of the kitchen during the serving process, which left the residents alone, at times. Resident #44 was sitting at a table by himself, facing the wall. Resident #44 had thickened juice on his table. He drank his juice and then coughed. During an interview on 5/2/19 at 10:04 a.m., staff member J stated resident #44 was on thickened liquids and pureed food and was eating in the independent dining room. During an interview 5/2/19 at 10:11 a.m., resident #44 had a hard time annunciating words and was not easily understood. Review of resident #44's Care Plan showed, Potential for Swallowing deficit noted on 4/5/18, ST evaluation dated, 4/19/18, the goal time was 7/29/19. Review of resident #44's MASA form - (Mann Assessment of Swallowing Ability Score) sheet, dated 4/5/18 showed, Dysarthria .speech unintelligible .Swallow integrity Dysphagia Aspiration .Probable dysphasia aspiration. Review of resident #44's ST - Therapist Progress & Updated Plan of Care notes, dated 5/3/18, showed, Treatment [DIAGNOSES REDACTED]. Review of resident #44's ST - Therapist Progress and Discharge Summary note, dated 5/15/18 showed, Goal not met on 5/15/18 The patient will tolerate a mechanical soft textures and thin liquid diet with the use of compensatory strategies 80% of the time without signs/symptoms of aspiration to optimize nutrition and hydration. Explanation maximum potential reached. Analysis of Functional Outcome/Clinical Impression Cooperative with P[NAME]. Agreeable to pureed textures and NTL. Review of resident #44's Diet and Fluid orders, dated 4/16/19, showed, Pureed .Level 4 Diet Mildly Thickened Liquids - .Level 2. 5. During an observation on 4/29/19 at 1:10 p.m., resident #29 was sitting in a rocking chair in the common area. He stated he needed to use the bathroom to staff G. Staff member G stated she would need to get assistance from another staff member to help him to the bathroom. Resident #29 used his walker to try and pull himself up, however he could not. Staff member G grabbed the waist band of the resident's sweat pants with her left hand and the residents arm with her right hand, and pulled him up. The resident's waist band stretched as he rose from the chair, which made him stumble. A gait belt was not used during this transfer for safety. During an interview on 4/29/19 at 1:22 p.m., staff member G stated she had a hurt neck, and she needed assistance to transfer the resident. However, resident #29 would not wait for another staff member to come help. She stated she should of instructed the resident to wait and should have used a gait belt instead of his pants and arm to help him up. Review of the facility policy Body Mechanics- transfer Training; with a revision date of 4/17, showed Gait Belts: a. Use a belt on residents for all assisted transfers, unless contraindicated. The transfer is safer for both resident and staff. Without a belt, there is nothing to hang on to that doesn't bruise, fracture or dislocate.

Based on observation, interview, and record review, the facility failed to assist the resident and provide a clothing protector so the resident's clothing would not get soiled during the meal, for 1 (#17) and the failure resulted in the resident's shirt becoming soiled; and failed to provide toileting assistance resulting in the resident becoming incontinent in her brief and having feelings of anger and embarrassment for 1 (#31) of 24 sampled residents. Findings include: 1. During an observation and interview on 5/1/19 at 8:33 a.m., resident #17 was feeding herself and had spilled oatmeal down the front of her shirt. The oatmeal had soaked into her shirt, and staff had not attempted to wipe it off or assist resident #17, with a way to protect her clothing from becoming soiled. Staff member M reported they did not have clothing protectors for residents in the facility. Staff member M reported they could use a towel. Resident #17 did not receive assistance from staff to have a towel placed on her clothing or a clothing protector during her meal. Staff member M wiped resident #17's shirt with a paper napkin and stated some family members bring in a clothing protector. Resident #17's shirt remained wet and stained after she was done with breakfast. Review of resident #17's Care Plan, under the heading, Problem, the plan showed need to maintain opportunity for personal choice to wear garment protector while eating with a start date of 4/23/19. Under the heading, Approach, the plan showed staff was to assure clothing protector is applied at the dining table during meals and snacks, and removed before leaving the table. Under Goals for the Problem it showed, maintain cleanliness of clothing. Maintain dignity and personal choice. Review of resident #17's Significant Change MDS, with the ARD of 11/13/18, showed her cognitive status was moderately impaired, and that she did not resist assistance with care. The MDS showed resident #17's preferences for family and social activities were very important to her. 2. During an interview on 4/30/19 at 10:24 a.m., resident #31 stated a concern that she sits in the bathroom for 10-15 minutes after she rings her call light. She stated she needed help with transfers because she broke her hip. She stated she has had to wait sometimes for over thirty minutes for staff to come and help her. She stated, One morning at about 4:00 a.m., it took them so long I had to pee myself. She stated the CNAs know I am having to wait a long time. She stated, It made me mad that I peed myself. She stated They knew I was mad. It happened the day before yesterday morning. Resident #31 stated if she had to go at 5:30 a.m. it was close to the shift change, and she would have to sit and wait. Resident #31 stated she did not know if it was affecting her daily routine. She stated she just [***] ed about it and went on with her life. During an interview on 4/30/19 at 4:53 p.m., NF5 stated he had concerns for the resident's care at the facility. NF5 stated there was a care plan meeting the next day, and he wanted to discuss his concerns after that meeting. During an interview on 5/1/19 at 4:40 p.m., resident #31 and NF5 reported several concerns. Resident #31 stated she liked to get out of bed at 7:00 a.m. to start her day. She stated staff get her up earlier on her bath days at 5:00 a.m. and if she doesn't want to get up then the staff tells her she needs to do it then or she would not get her bath. NF5 stated she had been told she had to do it when they could, or she would not get one. NF5 stated, at the last care plan meeting, he had reported the concern that staff had told the resident to go in her brief. He stated he was told that was not acceptable and should not have happened. He stated, at today's care plan meeting, he reported it happened again last week, so it had not quit. During an interview on 5/2/19 at 8:54 a.m., staff member N stated she answered call lights herself, early in the morning, usually from 5:45 a.m. to 8:00 a.m. She stated the CNAs are busy giving showers to the residents or in the resident rooms helping them get up for breakfast. She stated she had experienced working all three shifts, and from 4:00 a.m. to 5:00 a.m., was the least amount of staff, and all the call lights are going off. Staff member N stated, We just let them know we will get to them as soon as possible.

Based on observation, interview, and record review, the facility failed to follow physician's orders for a resident's POLST, with a DNR status, for 1 (#14) of 24 sampled residents. The facility failure caused unnecessary suffering and visible discomfort for resident #14. Findings include: During an observation on [DATE] at 12:34 p.m., resident #14 began having respiratory distress after consuming his liquids during the lunch meal. The resident displayed coughing, gurgling, shortness of breath and the resident's lips began to change in color, displaying signs of being cyanotic. The resident's cough sounded moist. During an observation and interview, on [DATE] at 12:47 p.m., staff member D stated, There are no orders to suction, he didn't want that, and his guardian didn't want that. Staff member D asked resident #14 if he wanted her to try to suction him. Resident #14 attempted to respond, but the only response that was heard from resident #14 was his verbal pitch changed, in the gurgling sounds he was making. During an observation on [DATE] at 1:48 p.m., and resident #14 had expired. During an interview on [DATE] at 1:11 p.m., staff member B stated It was just changed, everything should be in the chart. Staff member B stated You would have to ask the nurse if there was documentation regarding the conversation of no suctioning with the guardian and The new POLST is the same as the last one. During an interview on [DATE] at 1:37 p.m., NF3 stated she did not know that the guardian had stated she did not want resident #14 to have suctioning performed. NF3 stated Most of the facilities around here don't even have suctioning equipment. If they had suctioning, and the guardian agreed to it, then it would have been an appropriate intervention, but it would not have likely changed the outcome. NF3 stated, There was a report of upper respiratory symptoms with resident #14 on [DATE] that I was aware of, but stated she did not receive information from the staff that resident #14 had a suspected episode of aspiration. During an interview on [DATE] at 1:52 p.m., NF4 stated during the phone conversation staff member D stated resident #14 was doing well that morning (on day resident passed away), but the resident's oxygen saturation had dropped dramatically. NF4 stated, We did not discuss suctioning, we don't typically order that. I wouldn't want that going down my throat. Staff member D stated she wanted something for comfort for him because he was in distress. NF4 stated, I mentioned [MEDICATION NAME] (a medication), but they did not have that in the E-Kit (emergency medication kit). We were lucky to do anything with the [MEDICATION NAME]. During an observation and interview on [DATE] at 2:14 p.m., staff member B and [NAME] were able to locate where the emergency equipment was stored, which was next to the nursing station at the main dining room area. Staff member B stated in the event of an emergency they, would suction, apply oxygen, and start CPR until the emergency crew could get there. Staff member B stated with the recent event with resident #14, staff member D would have obtained the suction machine, but when she called the physician's office, staff member D stated she was instructed she was not to suction resident #14. During an interview on [DATE] at 9:47 a.m., staff member B stated resident #14 had aspirated sometime last week, and family did not want the resident transported to the hospital. Review of resident #14's nurse's note, dated [DATE], showed NF3 was updated regarding resident #14's condition, and showed to keep the resident comfortable and continue the nebulizer treatments. The nurse's note showed the resident's legal guardian had been notified, and the POLST had been updated. The nurse's note did not include documentation to show resident #14 was not to be suctioned or transported to the hospital. Review of resident #14's POLST, dated [DATE], showed DNR comfort measures only, and Relieve pain and suffering through the use medication by any route, positioning, wound care or other measures. Use oxygen, suctioning, and manual treatment of [REDACTED]. Transfer to hospital ONLY if comfort needs cannot be met in current location. The POLST lacked the physician's signature, but in the bottom right-hand corner of the POLST form, dated [DATE], it showed it was faxed to the provider on that same day. There was no documentation on the POLST that showed the guardian did not want resident #14 to receive suctioning or be transported to the hospital. (sic) A review of the facility's Policy, titled Cardiopulmonary Resuscitation or Do-Not-Resuscitate orders, dated ,[DATE], Showed under the heading Protocol . 10. DNR will designate that calling 911 and cardio-pulmonary resuscitation WILL NOT be done at the time of an arrest. In NO way does no CPR or DNR indicate that no treatment or procedures should be provided if a resident is acutely or chronically ill.

Based on observation, interview, and record review, the facility failed to ensure a resident was protected and free of abuse; and the facility failed to act on a report of verbal abuse by a staff member, which caused the resident to have ongoing fear and anger, for 1 (#34) of 13 sampled residents. Findings include: During an interview on 11/13/18 at 11:40 a.m., NF1 stated she reported an incident of verbal abuse to staff member C, About a month ago. She stated that her husband (resident #34) told her that a night nurse came into his room one evening and stated, What do you want? You are using the call light too often. NF1 stated that her husband was very upset by the remarks, so she wanted to make sure that the situation was addressed. She stated staff member C told her she would look into the situation, but had not followed up with her. During an interview on 11/13/18 at 11:45 a.m., resident #34 stated he was verbally abused by an overnight nurse that worked at the facility. He stated he could not recall the exact date of the incident, or who the staff member was, but he believed the incident took place just over a month ago. Resident #34 stated he had pushed his call light because he needed to use his urinal and a female nurse responded to the call. He stated the nurse entered his room and stated, What do you want? You need to stop using the call light all the time, we are busy! He stated the nurse did not assist him. Resident #34 stated her tone of voice caused him to be fearful and it angered him. Resident #34 stated facility staff did not ask him about the incident. He stated he was aware that his spouse reported the incident to staff member C, and he thought the incident was handled because the nurse had not provided care for him recently. During an interview on 11/14/18 at 3:52 p.m., staff member A stated she had not received any complaints regarding resident #34's care. She stated NF1, Has a closer relationship with (staff member C), so she may have brought it to her attention. Staff member A stated the facility investigated all allegations of resident abuse. She stated if an allegation of resident abuse was made, she would interview everyone involved in the allegation and she would involve the facility social worker. Staff member A stated she would notify the Ombudsman and report the allegation to the State Survey Agency. She stated an investigation was not completed because no allegation of resident abuse was brought to her attention. During an interview on 11/14/18 at 4:15 p.m., staff member C stated, I was never approached, by NF1 about an incident of verbal abuse that involved resident #34. During an observation and interview on 11/14/18 at 5:01 p.m., NF1 was observed sitting in the dining area with resident #34. When asked to provide clarification of who she reported the incident of verbal abuse to, NF1 pointed to staff member C's office, which could be observed from where she was sitting. NF1 stated she went to staff member C's office the day that she reported the incident. She stated staff member C was sitting at her desk and invited her into her office. NF1 could not recall the date that she made the report and stated, I'm sure it was a month or two ago. NF1 turned to resident #34 and asked him if he could recall the date. Resident #34 could not, but stated it was within that timeframe. Record review of resident #34's social service progress notes showed he had a BIMS score of 14; cognitively intact. Review of resident #34's social service progress notes, dated 9/14/18, showed resident #34 was, Alert and oriented He is able to express his needs .is able to make his own decisions. During an interview on 11/15/18 at 1:31 p.m., staff member A stated, all allegations of resident abuse, Would go to social services. She stated staff member C, does the investigations. During an interview on 11/15/18 at 2:05 p.m., staff member B stated she met with resident #34 and NF1 the prior evening. She stated NF1 confirmed with her that she reported an incident of verbal abuse to staff member C, A while ago. She stated she was not made aware of the report or allegation. During an interview on 11/15/18 at 2:11 p.m., staff member C stated she met with NF1 and resident #34. She stated NF1 told her that she came to her office to report an incident of verbal abuse to resident #34. Staff member C stated, I do not recall the event at all. She stated she reminded NF1 and resident #34 about a conversation they had previously about facility staff who were [MEDICATION NAME] and those that were less [MEDICATION NAME] than others, but NF1 told her that she reported the verbal abuse on a different day. Staff member C stated she updated resident #34's social service progress notes. Record review of resident #34's social service progress notes, dated 11/15/18 showed, SSD and DON met with (resident #34) and (NF1) (spouse) to discuss concerns .both reported that there had been an event in which a graveyard staff told (resident #34) that he is using the call light 'too much' and to 'stop calling because we are busy'. He stated the call light was then not on his table per his preference when he went to call for help again. The facility failed to protect resident #34 after abuse was reported and ensure he did not have ongoing harm, nor was subjected to ongoing verbal abuse by facility staff.

Based on observation, interview and record review, the facility failed to have sufficient staffing to provide the necessary care and services, to include: toileting and repositioning for 1 (#34) which resulted in urinary incontinence, pain, frustration, and fear for the resident; meal assistance and supervision in the dining room for 1 (#13) which had the potential to result in a resident aspirating; and failed to respond timely to resident call lights for 2 (#s 28 and 34) of 23 sampled and supplemental residents. Findings include: 1. During an observation and interview on [DATE] at 9:40 a.m., resident #34 was observed lying in his bed, on his back. Resident #34 stated he cannot reposition himself and he relied on staff. Resident #34 stated, Staff do not reposition me enough. He stated lying on his back was painful and his heels were beginning to burn. During an interview on [DATE] at 11:25 a.m., NF1 stated she only comes to visit her husband during the day. She stated, During the days, the staff tell me that there are only three CNAs here. NF1 stated the facility cannot get the staff that they need. When asked how long it took for staff to respond to her husband's call light, NF1 stated, On average, I would say about thirty minutes. NF1 stated her husband should be turned every two hours, but they don't do it. During an interview on [DATE] at 11:25 a.m., resident #34 stated that staff do not respond to his call light in a timely manner. He stated it made him frustrated and scared that staff did not respond promptly and sometimes it took over thirty minutes for staff to respond when he pushed his call light button. Resident #34 stated that he has had several incidents of incontinence because staff did not respond to him timely. During an interview on [DATE] at 1:31 p.m., staff member A stated that staffing, Had been rough all summer. She stated the facility experienced a lot of turnover that occurred, All at once. When asked if the facility had a policy regarding timely response to resident call lights, staff member A stated, I think when we are doing admissions, residents are told to give staff twenty minutes for their call light. She stated, Thirty minutes would be tops, when asked if it was appropriate for a resident to have to wait thirty minutes or more for a staff to respond to their call light. Review of resident #34's social service progress notes, dated [DATE] showed, resident #34 requested a room closer to the nurse's desk because he, Feels that his wait time for staff to answer his call light is bothersome. Review of resident #34's social service progress Notes, dated [DATE] showed, resident #34's spouse reported her husband, Is experiencing urgency in which he has had increased incontinence due to the need to wait for staff to help with toileting. 2. During an observation on [DATE] at 7:48 a.m., thirteen residents were observed sitting in the dining room eating breakfast. No staff were present in the room to provide supervision or assistance to the residents. During an observation on [DATE] at 8:34 a.m., six residents were observed sitting in the dining room eating their breakfast. No staff were present in the dining area to provide supervision or assistance to the residents. During an observation on [DATE] at 12:28 p.m., eleven residents were observed sitting in the dining room eating lunch. No staff were present in the dining area to provide supervision or assistance to the residents. Resident #13 began coughing loudly. After a few seconds, he was observed spitting something into his napkin. No staff member entered the dining area to ensure resident #13's safety. During an observation and interview on [DATE] at 12:34 p.m., staff member M was observed entering the dining area and walked around the room greeting residents. Staff member M stated staff are not present while the residents are eating and, There is supposed to be someone in here at all times, but there normally isn't. Staff member M stated she is not CPR or First Aid certified. On [DATE], the facility was requested to provide a policy for supervision of residents during meal times. The facility provided a policy titled, Meal Service Standards, revised on ,[DATE]. Review of the facility policy showed, the policy failed to identify expectations for staff to provide supervision to residents during meals. During an interview on [DATE] at 1:31 p.m., staff member A stated there is no supervision in the dining room because, We do not feel it is needed. When asked if the facility had a policy regarding the supervision of resident's during meals she stated, We gave that to you yesterday. 3. During a resident council meeting on [DATE], resident #28 stated residents of the facility do not get the care they need promptly. He stated, If you push a call light, it takes over a half hour for the staff to come. Resident #28 stated this made him feel like the staff do not care about him or the residents of the facility. When the residents in attendance were asked if they experienced similar issues, all residents stated it takes staff over a half an hour to respond to call lights.

Based on observation, interview, and record review, the facility failed to ensure a catheter drainage bag was kept lower than the level of the bladder, failed to provide education for a patient regarding the importance of keeping the catheter bag below the level of the bladder and maintaining aseptic storage of the drainage bag to reduce complications from urinary return resulting in urinary tract infections, obstruction and pain for 1 (#2) of 13 sampled residents. Resident #2 experienced recurrent urinary tract infections, urinary obstruction, and pain. These deficient findings had the potential to affect all residents with indwelling catheters. Findings include: Patient #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of resident #2's Annual MDS, with an ARD of 12/29/16, showed the resident had a BIMS score of 13, cognitively intact. Section (H0100) urinary appliances, showed the resident had an indwelling catheter. Review of resident #2's Physician Orders, dated 8/2017, showed: - (6/25/17) Urinary treatment: monitor supra-pubic catheter. Apply split sponge to side as needed. First ordered 2/25/14. - (10/13/15) Urinary treatment: change catheter bag and tubing as needed. First ordered 10/13/15. Review of resident #2's Care Plan, dated 12/17/13, showed, Problem dated 8/14/14: #6 suprapubic catheter placement. History [MEDICAL CONDITION] bacterial infection. Frequently refuses to allow staff to provide treatment. Urinary obstruction, acute [MEDICAL CONDITION]. Approach dated 12/17/13: Nurses, monitor cath placement site for signs or symptoms of infection, monitor output every shift and monitor for pain every shift. Goal dated 12/17/13: Will have adequate urinary output, will have no signs or symptoms at cath placement site. The goal time was dated 9/15/17. An update was made to the Care Plan on 1/11/17: Toileting: Suprapubic catheter. Encourage resident to cover his urinary drainage bag when he leaves his room, resident often refuses. Self/Independent for toileting. Review of resident #2's Care Plan failed to address the maintenance and placement of the urinary drainage bag placement while in his wheelchair and the need to re-educate the resident on risks associated with improper catheter bag placement. During an observation on 9/5/17 at 8:15 a.m., the resident was propelling himself in his wheelchair down the 300 hallway, toward the facility's main entrance. Resident #2 was holding an uncovered urinary bag up by his chest. During an observation on 9/5/17 at 8:30 a.m., resident #2 was sitting in his wheelchair at the end of the facility's parking lot smoking a cigarette. The resident had placed his uncovered urinary drainage bag on the ground, next to the wheel of his wheelchair. During an observation on 9/5/17 at 8:45 a.m., resident #2 was propelling himself in his wheelchair back down the 300 hall towards his room. Resident #2 was hugging his catheter bag, wrapped in white linen, to his chest. During an observation on 9/5/17 at 11:30 a.m., the resident was propelling himself in his wheelchair toward the facility's main entrance, his urinary drainage bag was in a black bag which was resting on his lap. During an interview on 9/5/17 at 11:45 a.m., staff member E stated resident #2 had a suprapubic catheter which the CNAs assisted him with emptying the catheter, but he was independent in his own cares. Staff member E stated she had noticed the resident would hold the catheter bag on his lap when he went outside. Staff member E stated resident #2 was independent in his wheelchair and did not place his drainage bag below his lap. She stated she had not provided resident #2 education on the risks associated with improper placement of the urinary drainage bag. She stated she was not aware if the resident was care planned for his suprapubic catheter. Staff member E stated she did not know the resident placed his drainage bag on the ground when he went outside. Staff member E stated resident #2 could be at risk for urinary tract infections and obstruction related to improper placement and management of his urinary catheter bag. During an interview on 9/5/17 at 1:00 p.m., resident #2 stated he did not have a place to hang his catheter bag, and there were no hooks for him to hang the catheter bag on his wheelchair. He stated he had a red and black cloth bag to put his drainage bag in when he went outside. He stated he did not always use the bags because they did not fit on his wheelchair and got in the way when he tried to wheel himself outside. He stated it was easy for him to place the drainage bag on his lap instead. Resident #2 stated he did not recall the staff educating him on the importance of keeping his drainage bag below his bladder. He stated the staff cleaned his catheter site and would assist in emptying and changing his drainage bag. He stated he also routinely had office visits with the urologist to change the suprapubic catheter. Resident #2 stated he recalled the urinary doctor had mentioned the importance of keeping the catheter bag below his bladder, but did not feel he could do that with the current storage bags. The resident stated when he goes outside, he placed the catheter bag, covered or not covered, on the ground next to his wheelchair. The resident stated he had never been educated on the importance of keeping his drainage bag off the ground. Resident #2 stated he was not sure why that would be a problem. During an interview on 9/5/17 at 1:30 p.m., staff member F stated resident #2 was non-compliant with keeping his urinary drainage bag off his lap. She stated the resident was independent with transferring himself from his recliner into his chair and managed his own catheter bag placement. She stated the resident was repeatedly educated to keep the urinary bag below his bladder and off his lap. She stated she did not remember if the different attempts at re-education on resident #2's drainage bag placement was documented. She stated she believed the resident was care planned for his suprapubic catheter, but was unsure if the placement of urinary catheter bag was care planned for the resident. Staff member F stated the resident was at risk for bladder spasms, urinary tract infections and obstructions when performing improper drainage bag placement. She stated she was not aware the resident placed the urinary drainage bag on the ground when he went outside. During an interview on 9/6/17 at 9:49 a.m., staff member D stated the resident would hold his catheter bag on his lap or up in the air while he propelled himself outside for a cigarette. She stated he went outside several times a day. Staff member D stated resident #2 was encouraged to hold the catheter bag below his bladder, but was non-compliant. She stated the resident had routine visits to see the urologist to check and change his suprapubic catheter. Staff member D stated the resident did not like using a leg bag because it would pull on the catheter site. She stated re-education was attempted daily for resident #2 to keep his drainage bag off his lap on below his bladder. She stated the physician had also spoke with the resident about the proper catheter bag placement. Staff member D stated the resident was at risk for urinary tract infections and bladder obstruction with the improper bag placement. She stated the resident had a history of [REDACTED]. The staff member stated she was not aware the resident placed his catheter on the ground when he went outside for a cigarette. During an observation on 9/6/17 at 9:50 a.m., resident #2 was sitting in his wheelchair at the end of the facility's parking lot having a cigarette. The resident's catheter bag was in a black bag and the bag was placed on the ground, next to the resident's wheelchair. During an interview on 9/6/17 at 10:00 a.m., staff member C stated she was aware the resident placed his urinary drainage bag on his lap when he left the facility for a cigarette. She stated he was routinely educated by staff to keep his catheter bag below his bladder, but the resident was non-compliant. She stated she did not believe the education attempts made by the staff regarding resident #2's bag placement were documented. The staff member felt the catheter was care planned but was not sure if the bag placement and re-education of the proper bag placement was care planned for resident #2. Staff member C stated the risk associated with improper catheter bag placement could result in the urine flowing back into the resident's bladder causing complications associated with urinary obstruction and urinary tract infections. The staff member stated she was aware resident #2 had experienced both complications associated with his urinary catheter. Staff member C stated it was the expectation of all staff to re-educate the resident on his placement of the drainage bag while in his room or in his wheelchair. She stated it would also be beneficial for the resident to be assessed and the risks associated with improper bag placement explained. She stated she was not aware if the resident had ever been educated on the risks associated with improper bag placement. She stated the facility had not considered using a back-flow valve for the resident to reduce risk of urinary back-flow while in his wheelchair. Staff member C stated she was not aware the resident placed his urinary drainage bag on the ground when he went outside for cigarette. During an observation on 9/6/17 at 10:55 a.m., resident #2 was sitting in his wheelchair at the end of the facility's parking lot having a cigarette. The resident's catheter bag was in a black bag which was placed on the ground next to the resident's wheelchair wheel. During an observation on 9/6/17 at 11:20 a.m., resident #2 had his catheter bag sitting on his lap. Staff member D asked the resident if he wanted to place the catheter bag lower on his chair. The resident explained to the staff member, there was no place for him to put his catheter bag on the wheelchair. During an interview on 9/6/17 at 11:30 p.m., resident #2 stated he was aware the contents of the drainage bag could flow back into his bladder if the bag was not kept below his lap. He stated he recalled having several urinary tract infections and bladder obstructions but did not realize that was because of the drainage bag placement. He stated the doctor had explained this to him, but he did not have a way to keep the catheter bag out of his way when he was in his wheelchair and the facility had not assisted him in finding an alternative method. Resident #2 stated he would like to try something different with his catheter bag to keep it from flowing back into his bladder and hurt me. During an interview on 9/7/17 at 10:44 a.m., staff member D stated resident #2 kept his catheter bag off his lap today when he went outside for a cigarette. Review of resident #2's Nursing Note, dated 8/1/16, showed, Saw (urologist) for scrotal swelling and penile pain. Orders received to [MEDICATION NAME] PO BID for bladder infection. Suprapubic catheter was changed per (urologist) at this visit as well. Review of resident #2's Nursing Note, dated 6/13/17, showed, 0400: Resident reports his suprapubic catheter is not draining, has discomfort. Urine is noted in bag, tubing. Attempt to flush suprapubic catheter is unsuccessful. Bladder is distended. 0530: Call to (PCP), order to see (urologist) by 0830-0900 if possible, if not send to ER or if resident is in increased discomfort send to ER. 0545: Resident is very uncomfortable and wishes to go to the ER for evaluation. 0600: Resident transferred via ambulance to (Hospital) for evaluation. 1352: Resident returned from (Hospital) ER at 0830 with a [DIAGNOSES REDACTED]. Order to start oral [MEDICATION NAME] 500mg BID for 1 week . Review of resident #2's After Visit Summary for the emergency room visit, dated 6/13/17, showed, Diagnosis: [REDACTED]. Lab Orders: urine culture with sensitivity. Medications Prescribed: [MEDICATION NAME] take 500mg by mouth twice daily. Review of resident #2's Urine Microbiology Report, dated 6/13/17, showed, culture results showed greater then 100,000 Colonies/[MEDICAL CONDITION] isolated. With resistance to ciprofloxiacin, [MEDICATION NAME], and [MEDICATION NAME]. Review of resident #2's Nursing Note, dated 6/16/17, showed, 2230: Order from (Hospital) to start Bactrim DS (1) tablet BID for 7 days [MEDICAL CONDITION]/UTI. 0200: Received order from (Physician), to discontinue [MEDICATION NAME]. Review of resident #2's Nursing Note, dated 8/13/17, showed, 0245: Resident had compliant of a lot of pain/discomfort to bladder area. Reports suprapubic catheter is plugged. Changed suprapubic catheter with 16 french and 10 ML balloon. With immediate urine return and resident reports relief and no further complaints of pain/discomfort. A review of the facility's policy and procedure titled, Catheter Management, showed, Purpose .all residents receive the appropriate care and services to prevent catheter-associated urinary tract infections. j. Unobstructed flow should be maintained to achieve a free flow of urine, the catheter and collecting tube should be kept from kinking; the collecting bag should be emptied regularly using a separate collecting container for each resident; poorly functioning or obstructed catheters should be kept below the level of the bladder, and not resting on the floor.

Based on interview and record review, the facility failed to provide interventions to prevent a severe weight loss, and provide interventions for a severe weight gain for 1 (#3) of 13 sampled residents. Findings include: a. Review of resident #3's annual weight report, showed a weight of 116 pounds on 12/26/16, and a weight of 86 pounds on 5/29/17. This was a 30 pound weight loss, 29% in six months, and considered severe. Review of resident #3's dietary note, dated 6/26/17, showed the resident continued to have a significant weight loss. R.D. is monitoring this bi weekly. (Resident) is refusing supplements. I was informed that these have been D.C.'d. R.D. is recommending an appetite supplement. Review of resident #3's dietary note, dated 6/29/17, showed This writer has seen resident multiple times, supplements have been tried, resident is refusing them per kitchen staff. Recommended consideration of appetite stimulant 5/25/17, no appetite stimulant has been added to med list currently, continue to recommend this as resident is refusing supplements and PO record indicates she is consuming 0-10% of meals, not meeting needs. Nutrition focused physical assessment reveals severe malnutrition as evidenced by severe hollowing at temple region, prominent clavicle and acromion process indicative of severe muscle loss. Recommend continue PO intake records x 1 month. Will continue to monitor weight status, other nutrition parameters. The note lacked interventions to prevent further weight loss. Review of resident #3's Physician Visit note, dated 7/12/17, showed She is eating poorly, and continues to lose weight. Her current weight is down to 89 pounds. Review of resident #3's Care Plan, dated 7/5/17, showed interventions dated 6/29/17 for: - Monitor weights - Monitor I and O - Administer medications as ordered, observe for side effects and effectiveness. - Monitor food intake. - Provide quiet meal environment. - Monitor diet is proper. - Supplements as ordered. 11/14/16 - Record food intake - Be positive in offering food Here I brought you something to eat. - Offer encouragement. - Encourage to try a variety of different foods. - Offer replacement food. - Offer snacks. The provided notes and care plan did not provide a root cause for the resident's poor appetite, effective interventions, and documentation of offered snacks, replacement foods, and a variety of different foods. During an interview on 9/6/17 at 1:15 p.m., staff member C stated the RD recommendation on 5/25/17, for resident #3 and the appetite stimulant, should have gone to the nursing department, and the physician contacted. She did not know why this had not happened. She stated the supplements were not working for resident #3. During an interview on 9/7/17 at 4:06 p.m., staff member L stated once she made a nutrition recommendation, it was out of her hands. The supplements were not working, and the resident's dementia was advancing. The appetite stimulant was not ordered until 7/16/17, two months after being recommended. b. Review of resident #3's annual weight report, showed a weight of 91 pounds on 7/10/17, and a readmit weight of 112 pounds on 8/7/17. This was an 18% significant and severe weight gain in one month. Review of resident #3's Nursing Charting note, dated 7/25/17, showed she had 4+ [MEDICAL CONDITION] and her left leg was weeping. Review of resident #3's Weight Log, showed her weight was up to 107 pounds on 8/1/17. Review of resident #3's Nursing Charting note, dated 7/28/17, showed increased [MEDICAL CONDITION], with a blistering area of fluid 3.5 cm X 2.5 cm. A dressing was ordered to protect the area. Review of the electronic record lacked evidence the physician was notified of the weight gain, identified on 8/1/17, or the weeping [MEDICAL CONDITION]. Review of resident #3's Physician visit, dated 8/9/17, showed she has been eating significantly poorly over the last few months and has been losing weight. Currently, same is present, not been eating well. The physician note identified the weight of 112 pounds, up from 89 pounds during the 7/12/17 visit. No new orders or analysis were provided regarding the weight gain. Review of resident #3's Dietary Note, dated 8/16/17, showed the resident was seen for a significant weight gain.(Resident) has gained 20 pounds x 1 month. Some of this weight is d/t water retention, severe BLE [MEDICAL CONDITION] currently. Some weight fluctuations is likely clinically unavoidable with continued diuretic use. No recommendations were provide regarding the 20 pound weight gain. During an interview on 9/6/17 at 1:30 p.m., staff member C stated the Physician should have been notified of resident #2's severe weight gain.

Based on observation, interview, and record review, the facility failed to prevent multiple falls, one with a hip fracture, and failed to implement interventions for falls for 4 (#s 3, 7, 10 and 12); and failed to assess the mobility status of a resident with a nonsurgical hip fracture for safety and comfort for 1 (#3) of 13 sampled residents. Findings include: 1. Review of the facility fall log for the past 12 months, showed resident #3 had 11 falls from 11/11/16 through 8/3/17. On 8/3/17, she fell and fractured her hip. Review of resident #3's Incident Reports, showed no incident reports for the falls on 11/11/16, 12/25/16, 1/6/17, 3/12/17, 3/16/17, 4/24/17(x2), and 7/12/17. Review of resident #3's Incident Report, dated 5/12/17, showed the resident was observed sitting on floor next to the side of the bed. Pad alarm did not sound at this time even though it was turned on. Pad alarm was determined to be semi-functional after the fall. No root cause was identified and no new interventions were implemented. Review of resident #3's Incident Report, dated 6/29/17, showed the alarm went off, and the resident was found lying on the floor. There was an injury to the left shoulder blade. The plan was to lower the bed, and was placed on the care plan, after 7 falls. No root cause was identified. Review of resident #3's Incident Report, dated 8/3/17, showed the resident was transferring out of the wheelchair and had an unwitnessed fall. She sustained a hematoma, superficial laceration, and a right hip fracture. The cause of the accident was weakness, confusion, and poor perception of ability to self-transfer. The chair alarm properly functioned. The steps to prevent recurrence were care plan updated. Review of resident #3's Care Plan, dated 10/26/16, with interventions dated 5/15/17, showed: - Instruct resident in use of adaptive equipment. The equipment was not identified. - Encourage to ask for assistance. The Quarterly MDS, dated [DATE]/7, showed the resident had severe cognitive impairment. - Assess changes in level of consciousness,and observe for functional decline due to psychotropic use. - Instruct on safety. - Monitor use of skidwear socks - Bedside table at bedside to prevent reaching - Maintenance of alarm functioning. - Maintain furniture in same arrangement. During an interview on 9/6/17 at 1:40 p.m., staff member C stated the interventions, including skidwear socks and the bedside table, were not effective in preventing falls. I do see what you are saying. She stated the facility had not evaluated the effectiveness of the alarms. During an interview on 9/7/17 at 10:10 a.m., resident #3 stated she absolutely hated them. (the alarms). 2. Review of the facility fall log for the past 12 months showed resident #10 fell seven times from 1/26/17 to 8/25/17. Six of the falls were in his room. Three involved the TV and the TV remote. Review of the two Incident Reports provided, were dated for a fall on 7/20/17 and 8/21/17. Review of resident #10's Incident Report, dated 7/20/17, showed resident #10 was trying to reach his light switch on the wall and fell out of his wheelchair. The Steps to Prevent Recurrence were Care Plan updated. Review of resident #10's Incident Report dated 8/21/17, showed the resident self-transferred to turn off the TV and fell . The Steps to Prevent Recurrence were Care Plan updated. Review of the fall log showed the fall on 4/21/17, occurred as resident #10 reached for his remote. Review of the fall log showed the fall on 4/24/17, occurred as resident #10 was agitated, as the television was on the wrong channel. He was on the floor. Review of resident #10's Care Plan, dated 1/13/17, with interventions dated 4/24/17, showed: - Assess change in level of consciousness, and changes in mood and behavior. - Instruct on safety. - Monitor for pain. - Encourage to ask for assistance. - Monitor that cushion is placed in recliner with dycem beneath. - Dycem in recliner and wheelchair. - Call light in reach and remind him to use. Resident #10's Care plan for fall prevention did not address the TV, the remote, and the preferred channel for the resident. During an observation on 9/7/17, there was no dycem on resident #10's recliner. During an interview on 9/7/17 at 2:40 p.m., staff member Q stated resident #10 hated his call light, and would not use it. 3. Resident #12 was admitted on [DATE]. The resident had [DIAGNOSES REDACTED]. Resident #12's BIMS showed severely impaired cognition. Review of the physician's orders [REDACTED].#12 was receiving Clonazepam 0.5 mg, three times a day, and as needed 0.5 mg twice a day; Depakote Sprinkles 250 mg, twice a day; Seroquel 200 mg, three times a day, and as needed 25 mg, three times a day. The resident's Care Plan, with a date of 7/21/17, showed, potential for adverse medication side effects which included gait changes, involuntary movements, and tremors. Review of the Incident Investigations, showed resident #12 fell eight times, from 7/21/17 until 9/6/17. - On 7/28/17 at 9:30 a.m., the resident was found on the floor, in an empty room. She had been ambulating in her wheel chair. There were no witnesses. The resident's seat, pressure alarm had been turned off by staff. The root cause was not identified. The investigation identified immediate interventions; reassess the pressure alarm operation and pattern of wandering, assess for anti roll back brakes on the wheel chair. The investigation identified no steps to prevent recurrence. - On 7/28/17 at 11:30 a.m., the resident was located in an empty room. The resident had been propelling around in a wheel chair. Staff heard resident #12's seat alarm going off. The resident was on the floor. The door was closed. The resident received a bruise on her lower, left arm. The investigation did not identify the root cause of why the resident was out of the chair and on the floor. The investigation identified no steps to prevent recurrence. - On 7/29/17 at 1:00 p.m., the resident was being wheeled out of the dining room in a wheel chair. The resident dropped her baby doll. The resident fell out of the wheel chair, onto her knees, while bent down, picking up the doll. The resident had an abrasion on her knee. The immediate intervention implemented was to secure the doll with Velcro or tie the doll onto the wheel chair. - On 7/29/17 at 8:00 p.m., the resident tripped on her feet, while standing, trying to reach her wheel chair. The resident was attempting to sit in the wheel chair. The resident scraped her left knee on the wheel chair. The investigation showed the cause of the fall was due to the fact the resident saw the wheel chair and had poor safety knowledge. Seeing the chair triggered her to self-transfer. The investigation did not identify why the resident wanted to get into the chair. The immediate intervention implemented was for gripper socks/appropriate foot wear and place the wheel chair by the bed. - On 8/6/17 at 3:05 p.m., the resident stood up from the wheel chair, the pressure alarm went off, and the resident sat down on the floor, next to the wheel chair. The investigation did not identify the root cause of why the resident stood up from the wheel chair. The investigation did not identify steps to prevent recurrence. - On 8/12/17 at 1:15 p.m., the resident had been in a stationary chair, got to the floor and was crawling when found. The investigation did not identify the root cause of why the resident had left the stationary chair and began crawling on the floor. Immediate intervention was to offer the bathroom and give the resident a snack. The investigation did not identify steps to prevent recurrence. - On 8/15/17 at 8:45 a.m., the resident was reaching and slipped out of the wheel chair, tearing the skin on her left elbow. The investigation did not identify the root cause of why the resident was reaching. The care plan was to be updated with a Dycem, a non slip material sheet, on her wheel chair seat. - On 8/21/17 at 4:00 p.m., the resident was found in the clean utility room, sitting on the floor. The facility followed the noise of the resident's chair alarm. The investigation did not identify the root cause of why the resident was in the utility room. The intervention included ambulation training needed for strength and steadiness. - On 8/21/17 at 4:15 p.m., the resident fell out of her wheel chair, and ended on the floor. The investigation did not identify the root cause. The investigation did not identify steps to prevent recurrence. Review of resident #12's Care Plan, with the date of 7/21/17, showed the facility had: - Put in place roll back brakes on resident #12's wheel chair. The resident's wheel chair was to be assessed to ensure the pressure alarm was on when the resident ambulated in the wheel chair and a bed alarm on the resident's bed. The care plan included keeping the call light in reach, and also to Observe, record, and report all unsafe conditions and situations, anticipate fall times. - Added to resident #12's care plan on 7/28/17, was to assess to ensure pressure alarm on wheel chair when resident ambulating. - Added to resident #12's care plan on 7/31/17, was the weight sensitive alarm on the wheel chair seat and the wheel chair was to be beside the bed, when the resident was in bed. - Added to resident #12's care plan on 8/1/17, Velcro was to be placed on the wheel chair arm, to secure the resident's baby doll. There was no documentation showing the facility's concern with the Velcro being an accident hazard related to the possibility of causing skin tears to the resident. - Added to resident #12's care plan on 8/1217, when in stationary lounge chair, not to put foot rest up unless staff was present at all times. During an observation on 9/7/17 at 8:54 a.m., staff member H and another staff member were walking resident #12. The wheel chair was behind resident #12. The baby doll was on the seat of the wheel chair. No Velcro was observed to hold the doll on. During an interview, on 9/7/17 at 8:54 a.m., staff member H stated the Velcro, to hold the baby in the chair, had not been put into place yet. During an observation on 9/7/17 at 9:00 a.m., resident #12 was in the wheel chair. The resident was pushing the chair with her feet. The wheel chair went around a corner, the baby doll fell out of the wheel chair. Resident #12 reached down to try and pick up the doll. The resident was leaning out of the chair. Staff member H reached for resident #12's shoulder, to hold the resident in the wheel chair. The staff member picked up the baby doll, off the floor and set on resident #12's lap. During an observation on 9/7/17 at 9:45 a.m., resident #12 was observed in her room. She was laying on her bed. A recliner was at the side of her bed towards the end, the wheel chair was next to the recliner, out of the resident's reach. A dresser was up against the bed, towards the head of the bed. The resident's walker was up against the bed to block the resident into her bed. A cognitively impaired person could possibly hurt themselves with no outlet from the bed. During an interview on 9/7/17 at 3:15 p.m., staff member C stated the wheel chair should have been next to resident #12's bed, easy to reach. During an observation on 9/7/17 at 1:57 p.m. staff member S shut the seat pressure alarm off of resident #12's wheel chair seat. The facility staff had not determined why resident #12 fell on five out of eight falls. Five out of eight falls, the facility staff had not identified steps to help prevent recurring falls. The facility staff had not determined if medications resident #12 was given would affect falls. Interventions, put in place, were either not followed by the facility staff, the resident was incapable of being able to use/comprehend the intervention, or interventions had not been put in place yet. 4. Resident #7 had [DIAGNOSES REDACTED]. Resident #7's BIMS showed he had severe, impaired cognition. Review of resident #7's Nursing Notes showed resident #7 had fallen five times, 2/11/17, 2/22/17, 5/10/17, 6/4/17, and 8/22/17, since the beginning of 2017. Review of an Incident Report, dated 2/11/17, showed resident #7 was found on the floor. The resident was trying to self-transfer, from the wheel chair to his bed, using the bed side table to steady himself. The resident was encouraged to use the call light instead of self-transferring. The action was to encourage the resident not to use the bed side table to steady himself. Review of an Incident Report dated 2/22/17, showed resident #7 was in his wheel chair, reaching for water on the dresser. The wheel chair tipped forward and resident #7 slid out of his wheel chair. The resident was reoriented to use the call light. Interventions to be implemented were to provide a reaching device, gripper socks, and remove wheelchair foot pedals. Review of the Incident Report dated 5/10/17, showed resident #7 was in bed, and took off his brief. The resident was reaching for the garbage, lost his balance, and rolled off the bed. The resident was educated on calling for help and not taking his brief off in bed. The intervention added, was to use a grab bar on the bed. Review of the Incident Report, dated 6/4/17, showed resident #7 slipped forward, while on the toilet reaching for his wheel chair, falling to the floor. Staff encouraged the resident to call for help instead of self-transferring. Review of the Incident Report, dated 8/22/17, showed resident #7 forgot to ring bell for assistance. Nursing wrote the resident was cognitive and the immediate intervention was to reorient to call light system and leave the door to his room open for visual checks. The resident was transferring from the bed to his wheel chair when he fell . During observations from 9/5/17 at 9:30 a.m., until 2:30 p.m., on 9/7/17, resident #7's door remained closed, unless staff went in to answer his call light. During an interview on 9/6/17 at 1:45 p.m., staff member C stated she was unaware resident #7 was not using a reacher/grabber. During an interview on 9/5/17 at 2:00 p.m., staff member P stated resident #7 did not have a reaching device in his room, and she never saw resident #7 use a reaching device. During an interview and observation on 9/6/17 at 9:25 a.m., resident #7 was in his room. The door was closed. Resident #7 was seated in his wheel chair, next to his bed. The mattress was above the resident's knee, not in the low position. The resident stated he did not have a reaching device in his room. Review of resident #7's Care Plan, with an update on 8/29/17, showed the care plan identified a low bed, call light in reach and by bedside, grab bars, fall mat, adaptive equipment (not specific), and encouragement to ask for help. Resident #7 was cognitively impaired and the facility staff were encouraging him to remember to use his call light. The incident reports showed interventions to be put in place, which were not adapted to the resident's safety plan, such as the reaching device, the low bed, and the open door. The non use of the interventions led to falls related to the same root cause, reaching and transferring, behind a closed door, where a cognitively impaired person lived. 5. Review of resident #3's discharge summary, dated 8/5/17, showed she returned to the facility, after a hospitalization , and was non-weight bearing on the right-sided hip fracture. During an observation on on 9/5/17 at 9:55 a.m., staff members H and K proceeded to transfer resident #3 out of bed to the commode, using two persons and a gait belt. Resident #3 stated it hurts. Staff cued her to stand on her good leg. Resident #3 was placed back into bed, and stated Ow, I have a broken hip, you know. During an observation on 9/5/17 at 4:00 p.m., staff members G and I took the resident to a shower room to use the commode. The staff cued her to use her good leg. Resident #3 asked should I drag my other leg? Staff member G stated they brought resident #3 to the shower room, because it was a better transfer, and she would not have to move or twist her hip. During an interview on 9/6/17 at 1:40 p.m., staff member C stated she did provide some CNA education for resident #3's transfers and bed positioning, but did not document it or put it on the Care Plan. During an interview on 9/6/17 at 2:50 a.m., staff member R stated the typical course for a non-surgical hip fracture was bed rest. She stated resident #3 wanted to get out of bed, so the physician said it was okay. She stated she really worried about resident #3's transfers, because the wrong movement could really damage and harm the hip. She did not evaluate the resident, or provide education for the CNAs for safe positioning and transfers, because staff member C was going to provide the education.

Based on interview, and record review, the facility failed to identify constipation concerns, did not try to implement a bowel program, therefore, the resident became impacted for 1 (#8) of 13 sampled residents. Findings include: Review of resident #8's physician orders, showed the resident had a [DIAGNOSES REDACTED]. Review of resident #8's nurses notes, dated 6/22/17 at 4:34 p.m., showed the resident impacted. Large amt stool noted and removed manually. Review of resident #8's physician orders, with a start date of 5/23/17, showed the resident had a physician order [REDACTED]. Review of physician orders, with a start date of 8/29/17, showed resident #8 was to receive Ducolax, 5 mg DR, one time daily, as needed. Review of physician orders, with a start date of 4/3/17, showed the resident was to receive Ducolax suppository, 10 mg rectal, daily as needed. Review of resident #8's bowel elimination from a 10 day period of observing ADLs, from 1/5/17 through 1/14/17, showed resident #8 did not have a bowel movement for the ten days staff observed. Review of resident #8's bowel elimination from a 10 day period of observing ADLs from 1/15/17 through 1/24/17/17 showed no documentation the resident had any bowel movements, during that time. Review of the resident's Incontinence Assessment-Bowel and Bladder 7-day tracker, dated 1/5/17 through 1/11/17 and 1/15 through 1/21/17 (14 days), showed the resident had a bowel movement 1/10/17 and 1/19/17 (2 days). Review of the facility forms, BM Chart, the MDS Observation form, Nursing notes, and Treatment sheets, dated from 5/1/17 through 9/5/17, showed resident #8 had no bowel movements from: - 5/1/17 until 5/8/17 (6 days) and 5/13/17 until 5/18/17 (5 days); - 6/19/17 until 6/24/17 (5 days); - 7/6/17 until 7/10/17 (4 days) and 7/13/17 until 7/18/17 (5 days); - 8/12/17 until 8/16/17 (4 days). The nursing notes, dated 5/1/17 through 9/5/17 (126 days), showed nursing staff had given resident #8 a [MEDICATION NAME] 5 mg DR tablet 12 times. Resident #8 refused the [MEDICATION NAME] suppository three times, when offered, during the time period. Review of resident #8 care plan with an update of 8/7/17 showed no documentation of identifying the resident's problem with constipation. Review of the physician progress notes [REDACTED].#8's bowel impaction. During an interview on 9/5/17 at 3:50 p.m., resident #8 stated she did not have consistent bowel movements and did have constipation at times. She stated she has used laxatives at times. During an interview on 9/6/17 at 8:04 a.m., staff member C stated resident #8 did have a problem with constipation. The staff member stated resident #8's bowel movements were tracked daily related to problems with constipation. We don't track everyone, just those with problems. Staff member C stated the facility did not have a bowel protocol, they individualized each resident. Generally it was a nursing judgement on when to give laxative to a resident. Normally on the third day, the nursing staff would contact the doctor.

Based on observation, interview and record review, the facility failed to ensure ongoing assessment and monitoring of 1 (#8) of 14 sampled residents after a fall, which resulted in a four hour delay in necessary evaluation and treatment. The facility failed to ensure there was an exchange of information between the [MEDICAL TREATMENT] clinic and the facility, pre and post treatment, for 1 (#10) of 2 residents who required [MEDICAL TREATMENT] treatment. The facility failed to ensure ongoing monitoring and assessment of a resident prior to and after the resident left the facility for [MEDICAL TREATMENT] treatment. The facility failed to follow the care plan for 1 (#12), which resulted in a decline in the resident's mobility. Findings include: 1. Resident #8 had [DIAGNOSES REDACTED]. Review of the resident's Incident Report, dated 8/20/16 at 5:00 p.m., showed resident #8 had an unwitnessed fall in the hallway. Review of resident #8's Incident Report under the section Description of Incident, showed the resident tripped in the North hallway and sustained a bruise to her mid upper lip, skin tears to both hands and knuckles, had a tooth knocked out, a laceration under the chin, and a skin tear to the right elbow. Under the section, Causal Factors, showed staff shortage for 8/20/16. Review of the resident's Neurological Flow Sheet, dated 8/20/16, showed a neurological assessment for 5:30 p.m., and 8:00 p.m. The resident's Neurological Flow Sheet did not show ongoing assessment of the resident's neurological status, or her injuries between 5:30 p.m. and 8:00 p.m. Review of the resident's nurse's note, dated 8/20/16, showed the resident was transferred to the ER via ambulance at 9:40 p.m., at the family's request. Review of the emergency room notes showed resident #8 was admitted with skin tears, a laceration, a contusion of the mouth with multiple missing teeth, upper and lower dentition, and a 2 cm laceration to her chin. Review of the resident's nurse's note, dated 8/21/16 at 3:42 a.m., showed the resident returned from the hospital, accompanied by family with both hands wrapped in gauze. Per the hospital nurse, the resident had skin tears on the tops of both hands, two sutures present under chin, bruising around the mouth and nose with swelling, and loss of teeth observed. The nurse's notes, dated 8/20/16, did not show assessment of the resident's injuries or neurological status between 5:00 p.m. and 9:00 p.m. Review of the resident's Office Visit note, dated 8/24/16, showed the resident had a significant fall on 8/20/16, with skin tears to bilateral hands and knocked out her front tooth. Review of the resident's MDS, with an ARD of 7/9/16, showed the resident wandered daily. Section G showed the resident needed limited assist by one staff for ambulation. Review of the resident's care plan showed poor spacial awareness. The resident's care plan did not show updates following the fall on 8/20/16. During an interview on 11/15/16 at 9:43 a.m., staff member B stated she would have sent the resident to the ER sooner. Staff member B stated staff should have had family come in sooner to evaluate the resident's injuries and decide whether the family wanted the resident sent to the ER for evaluation. Staff member B stated falls had not been consistently reviewed for discrepancies or accurate, complete documentation. Staff member B stated the following steps were expected following a fall: -Do not move the resident prior to a nursing assessment -The nurse should assess for alertness, range of motion, and injury -Start vital signs and neurological checks -Call physician if the resident has an injury -Notify the on call manager -Notify family Review of the resident's Fax Physician order [REDACTED]. The Fax Physician order [REDACTED]. The facility failed to provide documentation the resident's physician was notified of the resident's transfer to the ER for evaluation. Review of resident's nurse's note dated 8/20/16 at 9:40 p.m., showed the resident's physician was notified of the fall, via fax, at 9:00 p.m. During an interview on 11/17/16, at 7:40 a.m., staff member D stated staff member N requested assistance with an assessment and treatment of [REDACTED]. She stated the resident had skin tears, blood coming from her mouth, and a cut on her chin. Staff member D stated the resident's hands were wrapped. She stated the resident's range of motion was assessed. Staff member D stated the staff thought the resident caught the wheel of her walker and fell . She stated staff did not know when the resident was last visualized prior to the fall. She stated staff cleaned her up, put non-adherent dressings on the resident's hands and placed steri strips on her chin. Staff member D stated the family was notified. She stated she finished her charting and left the facility. She informed the staff she was the on call manager and gave instructions to contact the on call manager if anything changed. Staff member D stated staff did not let her know resident #8 was sent to the ER for evaluation. Staff member D stated staff member N was new to the facility and had not worked the unit assigned to him on 8/20/16. She stated he deferred to her decision to not send the resident to the ER for evaluation. Staff member D stated she viewed pictures which showed the resident's condition when the family arrived and stated the resident had started bleeding again. During an interview on 11/17/16 at 8:02 a.m., staff member B stated new nurses receive two weeks orientation prior to working the floor independently. Staff member B stated staff member N, on the day of the resident's fall, had been employed for five to six months. Staff member B stated the staff was not interviewed about the resident's location prior to the fall on 8/20/16. Staff member B stated the staff was not asked what time the resident was last seen prior to the fall. 2. Resident #10 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the nursing care plan on 11/16/16, showed resident #10 was scheduled to go to the local [MEDICAL TREATMENT] center for [MEDICAL TREATMENT] treatment on Mondays, Wednesdays, and Fridays. A review of resident #10's nursing notes from 8/1/16 through 11/14/16, did not show the resident left the facility for [MEDICAL TREATMENT] treatment except for one entry. On 11/14/16 at 2:47 p.m., the entry showed [MEDICAL TREATMENT] called and stated the resident's port was no longer patent, and the [MEDICAL TREATMENT] treatment center had made arrangements for the resident to go to a vascular surgeon tomorrow at 12:15 p.m. During an interview on 11/17/16 at 13:45 p.m., staff member O said that she was unaware resident # 10's port had not been patent on 11/14/16, and the resident had not been able to be dialyzed as scheduled. She was unaware that resident #10 had been scheduled for an appointment for evaluation for a new [MEDICAL TREATMENT] port. She also stated that usually the facility did not receive a report from the [MEDICAL TREATMENT] center regarding the resident's [MEDICAL TREATMENT] treatment before or after the resident was returned to the facility. The facility usually did not assess the resident or take the resident's vital signs after the resident returned to the facility from [MEDICAL TREATMENT] treatment. During an observation of resident's #10's [MEDICAL TREATMENT] port site on 11/17/16 at 1:30 p.m., staff member O removed the dressing from the resident's left upper chest to show large deep purple bruising around the port site and a moderate amount of dried blood surrounding the port skin opening site. During an interview on 11/17/16 at 1:40 p.m., resident #10's family member stated the resident had seen the vascular surgeon on 11/15/16, and he had been able to open the resident's port so that additional surgery for [REDACTED]. He also said the resident had been able to receive a complete [MEDICAL TREATMENT] treatment on 11/16/16. A review of resident #10's Nursing Progress notes from 11/14/16 to 11/17/16, did not show that the resident had seen a vascular surgeon regarding his nonpatent port and did not say the resident had been able to complete a [MEDICAL TREATMENT] treatment on 11/16/16. During an interview on 11/16/16 at 12:00 p.m., staff member G stated that the [MEDICAL TREATMENT] clinic usually did not give the facility a report on the residents after they received [MEDICAL TREATMENT]. She stated the [MEDICAL TREATMENT] clinic usually did lab work on the residents before and after their [MEDICAL TREATMENT] procedures, but that the results were not sent to the facility. She said she thought the facility sent the lab work to the residents' physician offices. She had never known the [MEDICAL TREATMENT] center to communicate the fluid amounts removed from the resident or share the resident's post [MEDICAL TREATMENT] vital signs. She stated that the facility usually did not do nursing assessments or vital signs on residents when they returned after [MEDICAL TREATMENT] treatments. She also said she was not aware that resident #10 had a nonpatent port on 11/14/16, or that the resident had seen a vascular surgeon on 11/15/16. During an interview of 11/16/16 at 12:30 p.m., staff member G stated the facility did not have a policy regarding nursing assessment of residents after returning to the facility from [MEDICAL TREATMENT] treatment. She said she had called the [MEDICAL TREATMENT] clinic and found out the clinic does not send resident lab work results done by the clinic to the residents' physicians. She said she was told there is not a contract between the local [MEDICAL TREATMENT] center and the facility. The [MEDICAL TREATMENT] center has been billing Medicare and Medicaid directly for the resident treatments. A review of resident #10's Care Plan showed facility staff are to monitor labs, monitor vitals, I&O. Monitor shunt site L arm. Report s/sx complications. During an interview on 11/17/16 at 1:00 p.m., staff member C said she was the only person who was responsible for updating resident care plans for the facility. She said she usually tried to update resident care plans at least once a quarter at the same time that she completed Quarterly MDSs for the residents. She stated she attended the daily morning standup report conferences to gain updated information regarding the residents, and then charted significant information on specific resident care plans on a daily basis. She stated the facility had not held a morning standup conference since the arrival of the survey team on 11/14/16. She stated that she did not know that resident #10 had missed [MEDICAL TREATMENT] on 11/14/16 because his port was not patent. She was unaware that the resident's port was sited in his upper left chest, and the site was significantly bruised when observed that morning on 11/17/16. 3. Resident #12 was admitted to the facility with the [DIAGNOSES REDACTED]. Review of the Annual MDS, with an ARD of 9/7/16, showed the resident needed limited assistance and was a one person physical assist. The resident wandered daily. The MDS showed the resident had a BIMS score of 00 (severely impaired). However, the MDS also showed the resident was usually able to be understood, and could sometimes understand others. Review of the care plan under potential for disruptive verbally and disruptive interaction, dated 11/10/16, showed staff were to offer a baby to ease the resident's anxiety, a task to redirect the resident's behavior, or offer sorting of laundry to redirect the resident's behaviors affecting others. Review of the Care Plan, under potential for medication side effects, dated 10/1/15, showed the resident was placed on a restorative walking program. The care plan showed to ambulate with front wheel walker and close wheel chair follow with assist of one, distances as tolerated, 3 times per day, and whenever she was restless and trying to stand up. During an observation on 11/15/16 in the activities room, the following occurred: -11:14 a.m. resident #12 stood, staff member GG asked her to sit down. Resident #12 made physical motion indicating she needed to use the bathroom. Staff member GG stated that it was just a part of her disease to ask to use the bathroom. -11:15 a.m., resident #12 stood during an interview and staff member HH asked the resident to sit back down. He did not provide the resident with an activity. -11:20 a.m., resident #12 stood and staff member HH helped her sit back down. Again, he did not provide her with an activity. -11:22 a.m., resident #12 stated that she needed to use the bathroom. No nursing staff was available. Another resident was yelling she needed to use the bathroom. Staff GG walked back into the room and stated hold on there is too much to do and left the room. Staff member HH told the residents needing to be toileted that nursing would be back in a few minutes to help. During an interview on 11/15/16 at 11:30 a.m., staff member R stated he did not do anything individualized for residents. During the interview there were 10 residents in activities, no nursing staff was available, and resident #12 continued to stand. The facility failed to follow the care plan approach because they did not provide an activity listed to redirect resident #12's behavior.

br>Based on interviews and record review, the facility lacked effective administration for 3 (#s 1, 2 and 3) of 4 sampled residents. These residents were identified as being affected by deficient practice during the survey. In addition, serious deficiencies were cited. IMMEDIATE JEOPARDY RELATED TO THE CARE OF RESIDENTS On 4/30/15 at 6:10 p.m., the administrator, DON, and a Corporate staff member, were notified by the survey team of an immediate jeopardy situation that existed in the areas of Resident Behaviors and Facility Practices and Administration. A total of six IJ citations were cited. PLAN TO REMOVE THE IMMEDIATE JEOPARDY The plan to remove the Immediate Jeopardy was verified onsite on 5/01/15 at 5:04 p.m. After the immediacy was removed, the scope and severity remained at a level of H. The facility's plan to resolve the immediacy reflected: 1. (Social Services Director) shall interview all Residents or Resident legal agents (with a trust account) to determine if other residents have perceived or experienced limited access to Resident funds. 2. All staff shall be educated, by staff member B, corporate, beginning immediately, on the facility Resident Safety Position Statement (abuse policy) which includes abuse prohibition, definition of abuse, staff responsibility to immediately report all allegations and protect residents from further abuse, and other elements required by law. Staff B, corporate, and staff member N, Regional Director, will do training for the Administrator, DON, and management Staff to include the Office Manager, Business Office Assistant, MDS Nurse and Dietary Manager beginning on 4/30/15 and will be completed by 5/1/15. 3. All staff shall be counseled as appropriate for failure to identify and report allegations of abuse in accordance with policy and regulation beginning 4/30/15. All staff shall be trained prior to working the next scheduled shift. All counseling will be completed by 5/1/15. 4. Facility staff shall be educated on the facility chain of command. In the absence of the Nursing Home Administrator and Director of Nurses, a staff member must be designated to oversee the operation of the facility during the administrator's absence. Additionally in the absence Nursing Home Administrator and Director of Nurses, the phone number to the Regional Director of Operations will be provided to staff. Abuse and Neglect Policy and Procedure/Chain of Command Education; A. Who to call or report to in specific situation in which the supervisor is accused. a. Nurse b. DON c. Administrator B. Chain of command reporting procedures d. Supervisor > Charge Nurse > DON > NHA > Corporate Office i. Department managers will receive numbers to the corporate office also posted on bulletin boards for employees. 5. Corporate Staff shall provide education on identifying at risk residents for abuse, in accordance with facility Resident Safety Policy. All staff shall be trained starting 4/30/15 and will be completed prior to the individual's next shift. The date, content, time and who attended the training will be available for the state agency. The training shall include the policy requirement for staff members who observe abuse to immediately intervene and separate/remove involved residents from the situation. °Characteristics of the resident population including but not limited to: °Residents with a history of aggressive behavior °Residents who have behaviors which might precipitate resident-to- resident abuse of any kind °Residents with self-injurious behaviors °Residents who have behaviors related to psychological or medical problems °Residents with communication disorders °Residents who require extensive nursing care °Residents who are totally dependent on staff 6. The facility will immediately forward all allegations of abuse to the regional director and/or VPO for review and consultation. The facility shall receive guidance on the investigation focus and content to ensure resident safety is assured and that a reasonable level of information obtained for the facility to determine appropriate interventions to prevent a reoccurrence of a similar event. Training will be conducted on and during the investigation process. Investigations shall remain on file. 7. The executive QAPI committee will review and identify facility system failures identified in the survey, policy implementation, and develop and implement a corrective action plan. Monitoring will be conducted no less than once per month by the management company via a review of QAPI minutes times 3 months. 8. All residents will have access to Resident trust monies without limitation unless restricted by the legal Resident agent or by regulation. 9. All resident trust funds shall be managed in accordance with applicable State and Federal regulation. 10. All residents shall receive discharge notices as required by regulation prior to discharge. 11. Resident #2's trust account monies (the $800.03) will be issued to him May, 2015. Resident #2 will also receive a statement. 12. Staff member A was counseled on 4/30/15. Written warning: given by staff member V, VP of Operations; Name of Employee: Staff member A, administration; regarding: 1: Resident Trust Management 2: Documentation 3: Allegation of abuse and neglect 4: Discharge notice To avoid further discipline, employee should follow all regulations of company and resident rights, monitor residents in parking lot, document behavior care plans with IDT. Report all allegations to supervisor. Manage funds per regulation. 13. The facility investigation into this matter is ongoing. 14. NHA and DON remain on desk duty with no resident contact until investigation concluded. 15. Corporate staff will complete monthly interviews with department manager times 3 months to assure no complaints have been made against the administrator. Please find the following steps to remove CREST Nursing Home from Immediate Jeopardy. All aforementioned steps will be completed by corporate staff or under corporate supervision. Findings include: The facility staff reported the alleged abuses for residents #2, 3 and 4 to the Corporate staff. The corporate staff, after becoming aware of the incidents of abuse, failed to identify potential abuse, failed to investigate the abuse, failed to identify the person(s) responsible for the alleged abuse, failed to protect residents from further abuse and failed to report the abuse and their findings to the appropriate state survey agency. The facility failed to have a policy and procedure that instructed staff to report alleged abuses outside of the facility at the corporate level if necessary. Subsequently, many staff that had knowledge of alleged abuses did not report the abuse. During interviews with staff, it was identified that alleged abuses were reported on three different occasions. One employee reported directly to the human resources staff person, one employee reported to the hotline, one corporate staff stated there had recently been an outside audit performed regarding resident trust funds due to an anonymous complaint. During a meeting on 4/30/15 at 6:10 p.m., and again at 6:46 p.m., the state agency notified the facility and corporate staff of an immediate jeopardy in the areas of abuse of resident behaviors and facility practices and administration. Specific abuses identified were mental abuse, involuntary seclusion and/or deprivation of resident trust funds for residents #1, 2 and 3. During an interview on 4/30/15 at 4:40 p.m., staff member F, DON, stated her last abuse training was in December 2014 by corporate staff. During an interview on 4/30/15 at 4:50 p.m., staff member A stated he had received abuse training by staff member N, regional director, approximately January 19th, 2015. He stated the training consisted of a paper review of the abuse policy. During the complaint investigation, staff stated resident # 2 and 3 were denied funds from their personal trust accounts. This accusation was known by staff and repeated in interviews. Accusations had been made against the administrator and were known to the management staff including the DON, SS, MDS, Activities Director, Maintenance, Dietary Manager, PT, and some nursing staff. Review of the Resident Safety Abuse Policy did not provide evidence of the procedure to contact corporate staff if an alleged abuse needed to be reported above the administrator. During an interview on 4/30/15 at 12:03 p.m., staff member N, regional director, stated he was not aware of any abuse allegations concerning resident #3. Allegations and mistreatment would be handled in the facility. He further stated there was a hotline available. During an interview on 4/30/15 at 3:25 p.m., corporate staff B, stated she spoke with the VP of operations and was told if a complaint came in on the hotline, it would come to either the VP of operations or the regional director and they had not see any reports. During an interview on 4/30/15 at 3:50 p.m., corporate staff W, HR, stated if an employee has an issue they wish to report, they can use the hotline. The hotline would summarize the phone call and send it to corporate staff member W. If it is an anonymous, it is forwarded to the RO and the nurse director. If it is not anonymous, she would call the complainant for more information. Corporate staff member W further stated she did get statements that administrator was rude to residents on 3/12/15. Staff member W further stated if the complaint is anonymous, it might not get investigated. During an interview on 5/1/15 at 11:45 a.m., staff member B stated the hotline is really for human resources. If they use the hotline, they should say this is for an abuse report. The hotline is really just for human resource issues. During an interview on 5/1/15 at 12:09 p.m., corporate staff members N and B, stated there was currently an ongoing investigation of abuse of resident trust funds being performed by an outside state agency. This complaint was triggered by an anonymous complainant. This audit was known at the corporate level and was not forwarded to the appropriate state agency. Cross reference tag F 223.

Based on record review and interview, the facility staff failed to ensure the residents were free from mental abuse for 3 (#s 1, 2 and 3), and involuntary seclusion for 1 (#2), and deprivation of resident trust funds for 2 (#s 2 and 3) of 4 sampled residents. This practice had the potential to affect all of the residents. IMMEDIATE JEOPARDY RELATED TO THE CARE OF RESIDENTS On 4/30/15 at 6:10 p.m., the administrator, DON, and a Corporate staff member, were notified by the survey team of an immediate jeopardy situation that existed in the areas of Resident Behaviors and Facility Practices and Administration. A total of six IJ citations were cited. PLAN TO REMOVE THE IMMEDIATE JEOPARDY The plan to remove the Immediate Jeopardy was verified onsite on 5/01/15 at 5:04 p.m. After the immediacy was removed, the scope and severity remained at a level of H. The facility's plan to resolve the immediacy reflected: 1. (Social Services Director) shall interview all Residents or Resident legal agents (with a trust account) to determine if other residents have perceived or experienced limited access to Resident funds. 2. All staff shall be educated, by staff member B, corporate, beginning immediately, on the facility Resident Safety Position Statement (abuse policy) which includes abuse prohibition, definition of abuse, staff responsibility to immediately report all allegations and protect residents from further abuse, and other elements required by law. Staff B, corporate, and staff member N, Regional Director, will do training for the Administrator, DON, and management Staff to include the Office Manager, Business Office Assistant, MDS Nurse and Dietary Manager beginning on 4/30/15 and will be completed by 5/1/15. 3. All staff shall be counseled as appropriate for failure to identify and report allegations of abuse in accordance with policy and regulation beginning 4/30/15. All staff shall be trained prior to working the next scheduled shift. All counseling will be completed by 5/1/15. 4. Facility staff shall be educated on the facility chain of command. In the absence of the Nursing Home Administrator and Director of Nurses, a staff member must be designated to oversee the operation of the facility during the administrator's absence. Additionally in the absence Nursing Home Administrator and Director of Nurses, the phone number to the Regional Director of Operations will be provided to staff. Abuse and Neglect Policy and Procedure/Chain of Command Education; A. Who to call or report to in specific situation in which the supervisor is accused. a. Nurse b. DON c. Administrator B. Chain of command reporting procedures d. Supervisor > Charge Nurse > DON > NHA > Corporate Office i. Department managers will receive numbers to the corporate office also posted on bulletin boards for employees. 5. Corporate Staff shall provide education on identifying at risk residents for abuse, in accordance with facility Resident Safety Policy. All staff shall be trained starting 4/30/15 and will be completed prior to the individual's next shift. The date, content, time and who attended the training will be available for the state agency. The training shall include the policy requirement for staff members who observe abuse to immediately intervene and separate/remove involved residents from the situation. °Characteristics of the resident population including but not limited to: °Residents with a history of aggressive behavior °Residents who have behaviors which might precipitate resident-to- resident abuse of any kind °Residents with self-injurious behaviors °Residents who have behaviors related to psychological or medical problems °Residents with communication disorders °Residents who require extensive nursing care °Residents who are totally dependent on staff 6. The facility will immediately forward all allegations of abuse to the regional director and/or VPO for review and consultation. The facility shall receive guidance on the investigation focus and content to ensure resident safety is assured and that a reasonable level of information obtained for the facility to determine appropriate interventions to prevent a reoccurrence of a similar event. Training will be conducted on and during the investigation process. Investigations shall remain on file. 7. The executive QAPI committee will review and identify facility system failures identified in the survey, policy implementation, and develop and implement a corrective action plan. Monitoring will be conducted no less than once per month by the management company via a review of QAPI minutes times 3 months. 8. All residents will have access to Resident trust monies without limitation unless restricted by the legal Resident agent or by regulation. 9. All resident trust funds shall be managed in accordance with applicable State and Federal regulation. 10. All residents shall receive discharge notices as required by regulation prior to discharge. 11. Resident #2's trust account monies (the $800.03) will be issued to him May, 2015. Resident #2 will also receive a statement. 12. Staff member A was counseled on 4/30/15. Written warning: given by staff member V, VP of Operations; Name of Employee: Staff member A, administration; regarding: 1: Resident Trust Management 2: Documentation 3: Allegation of abuse and neglect 4: Discharge notice To avoid further discipline, employee should follow all regulations of company and resident rights, monitor residents in parking lot, document behavior care plans with IDT. Report all allegations to supervisor. Manage funds per regulation. 13. The facility investigation into this matter is ongoing. 14. NHA and DON remain on desk duty with no resident contact until investigation concluded. 15. Corporate staff will complete monthly interviews with department manager times 3 months to assure no complaints have been made against the administrator. Please find the following steps to remove CREST Nursing Home from Immediate Jeopardy. All aforementioned steps will be completed by corporate staff or under corporate supervision. Findings include: Mental abuse, involuntary seclusion, and deprivation of resident funds. 1. Allegations of mental abuse. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During an interview on 4/29/15 at 10:48 a.m., Staff member A, administrator, said in care planning, we start talking about discharge on day one. The administrator said he felt the facility was capable of taking care of resident #1. The Administrator said, It was a prompt discharge. He (resident #1) was incapable of following rules and had been caught smoking in his room at least three times. He further stated that these incidents were documented in the nurse's notes and that he, the administrator, would document in the Social Services notes. He said he told resident #1 he was not welcome back. He said a 30-day notice was not given, and this was all safety driven, and the conversation only lasted about 30 seconds. Review of Section V, of the MDS, dated [DATE], showed the facility did not intend to develop a plan of care for discharge. Review of the Care Area Assessment summary, dated 3/10/15, did not show evidence that discharge planning was reviewed. Review of the Unmanageable Resident policy under Protocol #5 reflected; Unmanageable residents will not be retained by the facility. After consultation with the administrator, discharge proceedings will be implemented as instructed by the attending physician or medical director and in accordance with current laws and regulations governing such discharges. Protocol #6. The administrator will promptly notify corporate management of the incident. Protocol #7. Complete documentation of the incident must be recorded in the resident's medical record and an incident report completed and forwarded to the administrator and director of nursing. Review of incident reports provided by the facility did not include any behavioral incidents for resident #1, or any documentation that corporate management was notified of prompt discharge. During an interview on 4/28/15 at 8:45 a.m., staff member F, DON, said that the discharge was in the care plan. After the surgery, he intended to come back here, but the day of the surgery he was caught smoking in his room for the 2nd time. Staff member F said she thought the administrator had documented the discharge in the social service's notes. Review of the Care Plan showed there was no care plan done for discharge. Review of Social Service's notes did not reflect discharge planning or any incidents of smoking. During an interview on 4/29/15 at 10:48 a.m., staff member A, administrator, said the discharge planning would have been done by the Social Service Director and he was not sure if the discharge planning was documented. During an interview on 4/27/15 at 3:30 p.m., staff member C, said that staff member A, administrator, probably completed the discharge plan for resident #1 to go home. She said she had been off work for a week and when she returned, resident #1 had been discharged . Nursing notes reflected resident #1 had signed a document titled Smoking Rules on 3/10/15. The resident was counseled on smoking on 3/30/15 by staff member B, corporate staff, and the Smoking policy was reviewed. The resident had ashes in his window sill and had a BIMS score of 15. The resident gave staff his lighter and cigarettes and states he will sign out and go off the grounds to smoke. The note did not document discussion of possible consequences of smoking in the facility. Review of a nursing note, dated 4/03/15, the day of the surgery and discharge, showed the resident went out to smoke. Review of resident #1's care plan did not reflect any care planning for smoking. The facility incident notes did not show reported incidents of smoking for resident #1. During an interview on 4/28/15 at 1:00 p.m., resident #1 said staff member A, administrator, brought a bill to my room and laid it on my desk. He came in a while later and told me I had to pay the bill before the surgery. The administrator said I want you to go the the ATM at the hospital and get that money. I told him he was #1 with my middle finger. The administrator told me I was discharged and I did not come back after surgery. Me and him (administrator) had another incident that morning. He said to have all my[***]packed up before I went to the hospital. After the surgery, they brought me to my house. The resident further stated that he lives in a basement apartment by himself and when he got home after surgery, he was non-weight bearing on his leg. Resident #1 said he did not sign any discharge paperwork. During an interview on 4/28/15, at 3:50 p.m., (physician name) said the facility contacted her to request discharge orders for (resident #1) on 4/2/15. She said that she was not included in discharge planning for resident #1 or any resident. Review of the discharge orders written on 4/3/15 at 10:00 a.m., by (physician name), showed a telephone order was taken by staff member E, RN. Written as; Discharge to hospital for surgery. Patient is D/C from this facility. Review of the office notes of the (physician name) dated 4/3/15 showed, (facility name) called this a.m. to report resident #1 has been threatening to staff and other residents. He is leaving to (hospital name) today for surgery and is not welcome to return to the (facility name) after surgery. He will need to be discharged home with home health or to another facility. The physician notes did not mention smoking as a reason for discharge. Review of the Discharge Form filled out by the facility showed the resident refused to sign the form and the form did not give a reason for discharge. The facility notice did not reflect a right to appeal the transfer to the State, as well as the name, address and phone number of the state long term care ombudsman, and if mentally ill, the name, address and phone #, of the agency responsible of advocating of mentally ill individuals. Review of resident #1's [DIAGNOSES REDACTED]. Review of the nursing notes, incident reports and social services notes showed no documentation on the day of discharge. During interviews throughout the survey, staff members D, E, O, P, Q, J, and K, all stated they did not know resident #1 was not returning to the facility after surgery. 2. Allegations of Mental Abuse, Involuntary Seclusion, and Deprivation of Resident Funds. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, under B1000, dated 7/28/14, showed the resident had moderately impaired vision. A. During an interview 4/27/15 at 12:35 p.m. concerning resident #2, staff member G, RN, said, staff member A, administrator, told him to leave. She said in a stand-up meeting, she heard staff member A say, I pushed him out the door, and that he couldn't come back until he could behave, and I want him out of here. During an interview on 4/27/15 at 1:15 p.m, staff member H, said staff member A, stated at the stand-up report, resident #2 was pushed out the door because he was yelling and crying. She said staff member A said he told resident #2 that he could stay out until he could grow up. Staff member H said staff member A said he had hit the button and pushed resident #2 out. She said resident #2 told her he had gone to his home (his mother's house). Staff member H said she had heard the administrator say at morning report, I will do the same thing to resident #4 that I did to resident #2. During an interview on 4/27/15 at 3:30 p.m., staff member C said she thought resident #2 went out the front door on his own, and that she heard that resident #2 went out the front door and staff member A told him he could come back inside when he had calmed down. During an interview on 4/28/15 at 8:45 a.m., staff member F, DON, said she saw resident #2 and staff member A, administrator, in the parking lot. Resident #2 was using choice words. She said staff member A told her, I told him he needed to go outside and cool off. She said this all happened on March 16 . Staff member F said she and staff member A were going on a trip. When they were leaving for the airport, resident #2 was still in the parking lot and staff member A asked the resident if he had cooled off. Resident #2 said no. Staff member A said, If you are cooled off, you can go in. She said they left the facility and then staff member A called the facility to see if resident #2 was in yet and he wasn't, so staff member A, called the police and told them a resident might be leaving the facility. She also stated staff member A called the mother and told her resident #2 had left the facility. She did not know what the outside temperature was, but resident #2 rarely wore a jacket. She didn't know if he wore a jacket that day. Review of the weather history for Butte, the factor dated 3/16/15 at 10:53 a.m., reflected the temperature with wind chill factor was 38.6 degrees. The conditions were mostly cloudy. During an interview on 4/30/15 at 1:55 p.m., the Butte Police Department reported staff member A called on 3/16/15 at 11:12 a.m., to report the resident was out of the facility. During an interview on 4/30/15 at 11:25 a.m., staff member F, said her and staff member A left around 10:30 a.m. or 11:00 a.m. to go to the airport and that they were late. During an interview on 4/29/15 at 10:20 a.m., resident #2's mother stated resident #2 did not want to talk on the phone, so his mother asked the questions and he answered her. She said he was really upset and the administrator told him to get out of the building to calm down. He said staff member A, grabbed his chair and pushed him out of the building. He was told he could not come back into the building until he calmed down. During an interview on 4/28/15 at 2:32 p.m., staff member K said resident #2 told her, staff member A put him outside until he cooled off and resident #2 said how dare him. During an interview on 4/29/15 at 10:48 a.m., staff member A, administrator, stated resident #2 did not ever hurt anyone when his behaviors escalated. He was unsure what had been addressed for behaviors on resident #2's care plan. He said, we basically talked about trying to meet his psychological needs. When the DON and I were leaving for Minneapolis, resident #2 was screaming and I don't know what it was about. He said he was ninety percent sure it was about going to his mom's house. He further stated he did not know how long resident #2 was outside, because he and the DON left the area. He said he remembered hearing from the nurses, he (resident #2) came back inside. He stated usually the DON talked to resident #2. This was the only time he talked to him. Staff member A stated resident #2 went outside willingly. Staff member A said there were many occasions when resident #2 had to be moved into a more private environment because of his behaviors. A review of the care plan did not identify removing the resident to a private area or outside as an intervention to be used to address resident #2's behavior. The care plan was updated on 1/19/15 to address the goal of maintaining safety. On 3/16/15, the resident wheeled himself two miles through town to his mother's home. On 3/18/15 the care plan was updated to include signing out before leaving the building. The facility provided copies of the resident sign out sheets, however, the months of March and part of April 2015 were missing. During an interview on 4/29/15 at 4:55 p.m., staff member A, stated the sign out sheets for March and the first half of April were missing. He said, I do not know how that happened or that they are exactly the ones you are looking for. During an interview on 4/29/15 at 2:30 p.m., staff member M, maintenance, stated resident #2 was complaining about money, but I don't know any details. One time resident #2 was going home with his wheelchair and I chased him down with my car about 3 1/2 blocks to sign the check out book. He did not sign the book and said he was mad. He said something about money. I think I heard something about resident #2 being sent outside to cool off. Staff member M said he had no first hand knowledge of the incident. During an interview 4/30/15 at 2:30 p.m., resident #2's mother stated the facility called me. She said she worried about resident #2 going down Amherst and going across Harrison Avenue. She said she could not remember (resident #2) coming to her place before that date. During an observation drive on 4/30/15 along the route taken by resident #2 in his wheelchair to reach his mother's house, it was observed there were two stop lights and two busy main thoroughfares. The streets by his mother's house had multiple potholes and the sidewalks were not handicap accessible. A review of the nurse's notes dated 3/16/15 at 3:16 p.m., showed the nurse informed (physician name) that the resident left the facility without signing out first that morning. The note also said the resident claimed it was because he couldn't see, but wheeled himself all the way to his mother's house. The nurse also asked if the doctor wanted to let the resident leave the facility on outings. The resident returned to the facility at 2:00 p.m. A review of social services notes dated 3/16/15 at 12:26 p.m., showed documentation, Resident #2 has been leaving the building, wheeling himself to his mother's house, which is across town. Today he stated he was leaving, however refused to sign himself out. The DON called the police and they caught up with him as he arrived at his mother's home. The mother states he (resident name) can stay for a few hours at her home and then he must return. The return trip is a problem as they call and want staff to pick him up. He is aware we cannot provide that service. The Ombudsman has been called and left a message to call this writer back, due with (sic) his non compliance regarding signing in and out. (Resident name) yells out and continues to interrupt other residents as he is very loud. Requested nursing contact (resident's name) physician regarding his leaving the building and wheeling himself across town, which has been occurring daily since his eye surgery. Review of the Nursing Notes showed on 3/14/15 resident #2 was out of the facility. Documentation of resident sign out sheets were provided by the facility from 12/26/14 to 4/13/15 with the exception of the entire month of March through April 12, 2015. Review of the Unmanageable Resident policy under Protocol #5 showed; Unmanageable residents will not be retained by the facility. After consultation with the administrator, discharge proceedings will be implemented as instructed by the attending physician or medical director and in accordance with current laws and regulations governing such discharges. Protocol #6. The administrator will promptly notify corporate management of the incident. Protocol #7. Complete documentation of the incident must be recorded in the resident's medical record and an incident report completed and forwarded to the administrator and director of nursing. Review of incident reports provided by the facility did not include any behavioral incidents for resident #2, or any documentation that corporate management was notified. B. During an interview on 4/27/15 at 12:35 p.m., staff member G, RN, said that resident #2 owed money to the facility and had money in an account. She said that staff member A wouldn't let resident #2 have his money. She said that resident #2 told her that staff member A, administrator, had pushed him out the door. During the same stand up meeting it was reported staff member A, when referring to residents #s 3 and 4, said we will keep their money and we will do it until we get caught. During an interview on 4/27/15 at 1:15 p.m, staff member H, said resident #2 would want chips or candy and couldn't have any money. She said staff member A, administrator, would decide if resident #2 could or couldn't have money. She said resident #2 would argue with the administrator (while at the office window where residents can get money) when he couldn't get his money and the administrator would say to him, We have discussed this. You know what the rules are. If you don't behave in a proper way, you cannot have your money. During an interview on 4/27/15 at 3:30 p.m., staff member C said that staff member H would buy resident #2 chips. During an interview on 4/27/15 at 4:30 p.m., staff member I said that resident #2 had gone home and got $800, because he didn't have any money left in his account. In February or March he deposited the $800 for safe keeping. He wasn't given any of the $800. She said resident #2 did not know the money would go to pay the bill that he owed at the facility. She said that staff member A, administrator, said we should keep the money, because he wasn't getting any response from the mother. She said at first resident #2 was very upset about the money and asked for it a lot. After a couple of weeks he seemed to understand. If they owe money, we cannot give them what is in their account until the account is cleared. She said she had heard resident #2 and staff member A, administrator, at the window talking about the money. During an interview on 4/28/15 at 8:45 a.m., staff member F, DON, said resident #2's mother had given the facility money. The mother told the facility that resident #2 was saving up and it was his money. She said that resident #2 asked her for money on a Saturday, but she was unable to access it. Staff member F thought resident #2 bought games and movies with the money. During an interview on 4/28/15 at 10:45 a.m., staff member J, RN, said resident #2 was coming out of the administrator's office and saying the facility took his money to make a payment. Resident #2 had said taking money is against the law and they took my money. Resident #2 told her that he had $800 and it got used for a payment. She said she would hear him at the office, yelling and asking for money. Staff member J said resident #2 told her that was his own money and he hadn't expected the money to be used here. During an interview on 4/28/15 at 2:20 p.m., resident #2's mother said it was resident #2's money. He had saved it for many months and thought it was for him to have. She said she brought money in and gave it to her son. He told the office he had it and they told him they would keep it safe for him and they would give it to him when he asked for it. They stated it was to pay for the expenses for the last five months that he was there, and they would hold it because of non-payment. He purchased the games and things out of his monthly money, but not out of that money. During an interview on 4/28/15 at 5:00 p.m., staff member L, RN, said resident #2's mom brought money into the facility and they were under the impression that resident #2 would get the full amount of it. Staff member L overheard the business office saying it was to cover costs. Admit orders were reviewed on page 8: If the resident utilizes moneys received from Social Security or a similar source to pay for a share of the cost and the Resident fails to make prompt payment, the Facility may require direct mailing of such money to the Facility. In some states, failure to pay the Resident's share of the cost may result in the Resident's discharge. The Facility will also notify the appropriate State or Federal agency of this non-payment. This path of correction was not utilized by the facility. During an interview on 4/30/15 at 4:54 p.m., staff member A, administrator, said I have no idea of the sums of money he would ask for. I do not know if he was aware of the money. He would just ask for $5 or $10 dollars to buy games. He owes $4400 and he has not paid one portion of his medicaid mandated portion. He also stated he did not request the Social Security money to be sent to the facility. He said, I had filled out the paper work to become the payee, but did not send it in, however, he did not talk to APS about the situation. Review of the Resident fund ledger for resident #2, showed the $800 deposit was made on 3/19/15. The copy of the bank deposit showed the money was deposited on 3/19/15. No withdrawals were made from resident #2's account from that point forward. Resident #2 was discharged on [DATE] and on 4/29/15 the money was still being held in an account by the facility. Review of the care plan showed that money management was not addressed for resident #2. 3. Allegation of Mental Abuse and Deprivation of Resident Funds. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care area assessment showed [DIAGNOSES REDACTED]. The resident represents himself and does not have a POA. Review of the Significant change MDS dated [DATE] under section V, the care area assessment summary, showed a facility intention to care plan for behavioral symptoms. Review of the Care Plan dated 12/17/14 showed: PROBLEM #1: resident becomes intoxicated when he is out in the community and is at risk for injury; Approaches: 1) Nurses are to make sure the resident signs out when leaving the building and make sure all medications should be administered. Notify MD. 2) 1:1 visits with social services, encourage financial redirection especially during the first of the month with offers of purchasing items he needs and desires. Ongoing discussion and assistance regarding discharge plan. 3) Activities: inform of activities, perform shopping for personal items. GOAL: Discourage outings in the community where alcohol is involved. Will participate in activity. Will communicate fears to staff. PROBLEM #2: Cognitive Deficit. Uses alcohol when in the community. Approach: If resident leaves the building and cannot get a way home we do not go get him. Update MD on status on each episode. GOAL: Occurrences minimized. Review of the Unmanageable Resident policy under Protocol #5. Unmanageable residents will not be retained by the facility. After consultation with the administrator, discharge proceedings will be implemented as instructed by the attending physician or medical director and in accordance with current laws and regulations governing such discharges. Protocol #6. The administrator will promptly notify corporate management of the incident. Protocol #7. Complete documentation of the incident must be recorded in the resident's medical record and an incident report completed and forwarded to the administrator and director of nursing. Review of the incident reports showed an incident that occurred on 12/12/14 showing resident fell in his room while intoxicated. On 3/13/15, there was an incident report of the resident being found on floor in his room while intoxicated. No other incident reports were documented for resident #3. Review of the facility resident trust withdrawal records showed each month resident #3 had withdrawn $30.00 as one lump sum from his account from 1/12/14 through 12/1/14. After 12/1/14, the withdrawals became sporadic. From 3/20/15, all personal withdrawals were less than $10.00. From 4/1/15, all withdrawals have been less than $5.60. During the months of March and April of 2015 resident #3 was only able to get: 3/20/15 shopping $8.90; 3/24/15 personal $5.00; 3/27/15 personal $6.00; 4/01/15 snacks $2.58; 4/03/15 personal $5.00; 4/10/15 personal $5.60; and 4/23/15 shopping $1.79. During an interview on 4/28/15 at 1:50 p.m., resident #3 stated sometimes the director tells me no, because I will go drink. I can drink if I want, I just don't want to. I don't have an agreement, he just came off the walls with that. I'm going to call the Ombudsman. I want to buy cigarettes, pop, beer. One pack of cigarettes will last 3 weeks. I wanted to go to the store today, the girl gave me money. She doesn't know the policy. If (name) staff member A was here, I would have had to talk to him to get money. I have problems getting money ever since this guy became the director. I can't even go downtown on the bus. Last Saturday, I fell down in town and went to the hospital. He (staff member A) said I am not going downtown no more. Staff member A, administrator was hired at the facility in December 2014. During an interview on 4/29/15 staff member A, administrator, stated resident #3 was not allowed to go into town. He also stated that 100% of the time, resident #3 has come back by bus or police or gone to the ER if he has more than $5.00. Staff member A said resident #3 is his own person. Review of physician progress notes [REDACTED].we will not provide him with money if he leaves the building and close monitoring by strict instructions on when, how long and where he is going. This plan is agreed upon by resident #3. Resident can receive small amounts of money for in facility use. This document was signed by the administrator, but not by resident #3. Review of the incident reports showed there was no documentation of an incident repo

br>Based on interviews and record review, the facility lacked effective administration for 3 (#s 1, 2 and 3) of 4 sampled residents. These residents were identified as being affected by deficient practice during the survey. In addition, serious deficiencies were cited. IMMEDIATE JEOPARDY RELATED TO THE CARE OF RESIDENTS On 4/30/15 at 6:10 p.m., the administrator, DON, and a Corporate staff member, were notified by the survey team of an immediate jeopardy situation that existed in the areas of Resident Behaviors and Facility Practices and Administration. A total of six IJ citations were cited. PLAN TO REMOVE THE IMMEDIATE JEOPARDY The plan to remove the Immediate Jeopardy was verified onsite on 5/01/15 at 5:04 p.m. After the immediacy was removed, the scope and severity remained at a level of H. The facility's plan to resolve the immediacy reflected: 1. (Social Services Director) shall interview all Residents or Resident legal agents (with a trust account) to determine if other residents have perceived or experienced limited access to Resident funds. 2. All staff shall be educated, by staff member B, corporate, beginning immediately, on the facility Resident Safety Position Statement (abuse policy) which includes abuse prohibition, definition of abuse, staff responsibility to immediately report all allegations and protect residents from further abuse, and other elements required by law. Staff B, corporate, and staff member N, Regional Director, will do training for the Administrator, DON, and management Staff to include the Office Manager, Business Office Assistant, MDS Nurse and Dietary Manager beginning on 4/30/15 and will be completed by 5/1/15. 3. All staff shall be counseled as appropriate for failure to identify and report allegations of abuse in accordance with policy and regulation beginning 4/30/15. All staff shall be trained prior to working the next scheduled shift. All counseling will be completed by 5/1/15. 4. Facility staff shall be educated on the facility chain of command. In the absence of the Nursing Home Administrator and Director of Nurses, a staff member must be designated to oversee the operation of the facility during the administrator's absence. Additionally in the absence Nursing Home Administrator and Director of Nurses, the phone number to the Regional Director of Operations will be provided to staff. Abuse and Neglect Policy and Procedure/Chain of Command Education; A. Who to call or report to in specific situation in which the supervisor is accused. a. Nurse b. DON c. Administrator B. Chain of command reporting procedures d. Supervisor > Charge Nurse > DON > NHA > Corporate Office i. Department managers will receive numbers to the corporate office also posted on bulletin boards for employees. 5. Corporate Staff shall provide education on identifying at risk residents for abuse, in accordance with facility Resident Safety Policy. All staff shall be trained starting 4/30/15 and will be completed prior to the individual's next shift. The date, content, time and who attended the training will be available for the state agency. The training shall include the policy requirement for staff members who observe abuse to immediately intervene and separate/remove involved residents from the situation. °Characteristics of the resident population including but not limited to: °Residents with a history of aggressive behavior °Residents who have behaviors which might precipitate resident-to- resident abuse of any kind °Residents with self-injurious behaviors °Residents who have behaviors related to psychological or medical problems °Residents with communication disorders °Residents who require extensive nursing care °Residents who are totally dependent on staff 6. The facility will immediately forward all allegations of abuse to the regional director and/or VPO for review and consultation. The facility shall receive guidance on the investigation focus and content to ensure resident safety is assured and that a reasonable level of information obtained for the facility to determine appropriate interventions to prevent a reoccurrence of a similar event. Training will be conducted on and during the investigation process. Investigations shall remain on file. 7. The executive QAPI committee will review and identify facility system failures identified in the survey, policy implementation, and develop and implement a corrective action plan. Monitoring will be conducted no less than once per month by the management company via a review of QAPI minutes times 3 months. 8. All residents will have access to Resident trust monies without limitation unless restricted by the legal Resident agent or by regulation. 9. All resident trust funds shall be managed in accordance with applicable State and Federal regulation. 10. All residents shall receive discharge notices as required by regulation prior to discharge. 11. Resident #2's trust account monies (the $800.03) will be issued to him May, 2015. Resident #2 will also receive a statement. 12. Staff member A was counseled on 4/30/15. Written warning: given by staff member V, VP of Operations; Name of Employee: Staff member A, administration; regarding: 1: Resident Trust Management 2: Documentation 3: Allegation of abuse and neglect 4: Discharge notice To avoid further discipline, employee should follow all regulations of company and resident rights, monitor residents in parking lot, document behavior care plans with IDT. Report all allegations to supervisor. Manage funds per regulation. 13. The facility investigation into this matter is ongoing. 14. NHA and DON remain on desk duty with no resident contact until investigation concluded. 15. Corporate staff will complete monthly interviews with department manager times 3 months to assure no complaints have been made against the administrator. Please find the following steps to remove CREST Nursing Home from Immediate Jeopardy. All aforementioned steps will be completed by corporate staff or under corporate supervision. Findings include: Immediate Jeopardy was identified for 3 (#s 1, 2, and 3) of 4 sampled residents for failure to protect from abuse. 1. Protection from abuse. The facility failed to protect resident #1 from mental abuse, by discharging resident #1 abruptly without providing the resident information on the right to appeal, the name, address and phone number of the state long term care ombudsman and the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals. The facility also demanded resident #1 go to the hospital prior to surgery and get money from an ATM machine to pay his facility bill. The resident was also demanded to pack his belongings and take them with him when leaving for surgery. He was advised he was not welcome back at the facility. Cross reference tag F223. The facility failed to protect resident #2 from mental abuse, involuntary seclusion and deprivation of resident funds. Resident #2 was pushed or assisted to the parking lot of the facility during a verbal outburst involving the administrator. The resident was told he could not return to the facility until he had calmed down. The resident was denied access to personal funds he had placed in the resident trust account. Cross reference tag F223. The facility failed to protect resident #3 from mental abuse and deprivation of funds. Resident #3 was denied access to personal funds in the resident trust account. The resident is his own representative and was denied access to his funds in the amounts he requested and was told he had to request the funds from the administrator who would determine if and how much he could have. Cross Reference Tag F223. Scope and severity was a pattern with immediate jeopardy. 2. Failure to report and investigate abuse allegations. Staff with knowledge of alleged abuses toward residents #2 and #3' failed to report the abuses. The facility failed to investigate abuses reported at the corporate level and on the hot line. Cross reference Tag F 225. The scope and severity was isolated with immediate jeopardy. 3. Failure to develop and implement policies to prevent abuse. The facility failed to report timely and investigate allegations of abuse for residents #s 2 and 3. The facility failed to educate staff on the chain of command for abuse reporting. Cross reference Tag F226. The scope and severity was a pattern with immediate jeopardy. 4. The facility failed, at the corporate level, to thoroughly educate management staff to identify, report, and investigate abuse. The current administrator was trained in January, 2015 and reported the training was a review of the abuse policy. Cross reference Tag F493. The scope and severity was widespread with immediate jeopardy. 5. Resident #2 had been identified in a previous investigation that resulted in immediate jeopardy (IJ), dated 10/30/14, when he was told he could not come out of his room because he had played with his stool (bowel movement). Review of the facility's plan of correction for the above IJ, reflected that staff education was conducted on abuse and immediate reporting requirements and professional conduct. In addition, all staff were educated on identifying at-risk residents for abuse. The training included the policy requirement for staff members who observe abuse to immediately intervene and separate or remove the involved resident from the situation. The facility failed to achieve sustained substantial compliance. Cross reference Tag F520 The scope and severity was widespread with immediate jeopardy. As of 5/12/15 at 1:15 p.m., the facility has not provided information of the alleged abuse of residents #1 and 3. Furthermore, the facility has not reported to the state agency any details regarding the anonymous complaint and investigation into the resident trust funds.

br>Based on record review and interviews, the facility failed to sustain substantial compliance of tags F 223, 225, 226 and 490, which were identified in a complaint survey conducted on 10/30/14, with F 225, 226 and 490 identified at an immediate jeopardy level and F223 was identified at a level of harm. The facility QAPI program failed to effectively implement, monitor, evaluate and revise QAPI action plans related to abuse prevention. IMMEDIATE JEOPARDY RELATED TO THE CARE OF RESIDENTS On 4/30/15 at 6:10 p.m., the administrator, DON, and a Corporate staff member, were notified by the survey team of an immediate jeopardy situation that existed in the areas of Resident Behaviors and Facility Practices and Administration. A total of six IJ citations were cited. PLAN TO REMOVE THE IMMEDIATE JEOPARDY The plan to remove the Immediate Jeopardy was verified onsite on 5/01/15 at 5:04 p.m. After the immediacy was removed, the scope and severity remained at a level of H. The facility's plan to resolve the immediacy reflected: 1. (Social Services Director) shall interview all Residents or Resident legal agents (with a trust account) to determine if other residents have perceived or experienced limited access to Resident funds. 2. All staff shall be educated, by staff member B, corporate, beginning immediately, on the facility Resident Safety Position Statement (abuse policy) which includes abuse prohibition, definition of abuse, staff responsibility to immediately report all allegations and protect residents from further abuse, and other elements required by law. Staff B, corporate, and staff member N, Regional Director, will do training for the Administrator, DON, and management Staff to include the Office Manager, Business Office Assistant, MDS Nurse and Dietary Manager beginning on 4/30/15 and will be completed by 5/1/15. 3. All staff shall be counseled as appropriate for failure to identify and report allegations of abuse in accordance with policy and regulation beginning 4/30/15. All staff shall be trained prior to working the next scheduled shift. All counseling will be completed by 5/1/15. 4. Facility staff shall be educated on the facility chain of command. In the absence of the Nursing Home Administrator and Director of Nurses, a staff member must be designated to oversee the operation of the facility during the administrator's absence. Additionally in the absence Nursing Home Administrator and Director of Nurses, the phone number to the Regional Director of Operations will be provided to staff. Abuse and Neglect Policy and Procedure/Chain of Command Education; A. Who to call or report to in specific situation in which the supervisor is accused. a. Nurse b. DON c. Administrator B. Chain of command reporting procedures d. Supervisor > Charge Nurse > DON > NHA > Corporate Office i. Department managers will receive numbers to the corporate office also posted on bulletin boards for employees. 5. Corporate Staff shall provide education on identifying at risk residents for abuse, in accordance with facility Resident Safety Policy. All staff shall be trained starting 4/30/15 and will be completed prior to the individual's next shift. The date, content, time and who attended the training will be available for the state agency. The training shall include the policy requirement for staff members who observe abuse to immediately intervene and separate/remove involved residents from the situation. °Characteristics of the resident population including but not limited to: °Residents with a history of aggressive behavior °Residents who have behaviors which might precipitate resident-to- resident abuse of any kind °Residents with self-injurious behaviors °Residents who have behaviors related to psychological or medical problems °Residents with communication disorders °Residents who require extensive nursing care °Residents who are totally dependent on staff 6. The facility will immediately forward all allegations of abuse to the regional director and/or VPO for review and consultation. The facility shall receive guidance on the investigation focus and content to ensure resident safety is assured and that a reasonable level of information obtained for the facility to determine appropriate interventions to prevent a reoccurrence of a similar event. Training will be conducted on and during the investigation process. Investigations shall remain on file. 7. The executive QAPI committee will review and identify facility system failures identified in the survey, policy implementation, and develop and implement a corrective action plan. Monitoring will be conducted no less than once per month by the management company via a review of QAPI minutes times 3 months. 8. All residents will have access to Resident trust monies without limitation unless restricted by the legal Resident agent or by regulation. 9. All resident trust funds shall be managed in accordance with applicable State and Federal regulation. 10. All residents shall receive discharge notices as required by regulation prior to discharge. 11. Resident #2's trust account monies (the $800.03) will be issued to him May, 2015. Resident #2 will also receive a statement. 12. Staff member A was counseled on 4/30/15. Written warning: given by staff member V, VP of Operations; Name of Employee: Staff member A, administration; regarding: 1: Resident Trust Management 2: Documentation 3: Allegation of abuse and neglect 4: Discharge notice To avoid further discipline, employee should follow all regulations of company and resident rights, monitor residents in parking lot, document behavior care plans with IDT. Report all allegations to supervisor. Manage funds per regulation. 13. The facility investigation into this matter is ongoing. 14. NHA and DON remain on desk duty with no resident contact until investigation concluded. 15. Corporate staff will complete monthly interviews with department manager times 3 months to assure no complaints have been made against the administrator. Please find the following steps to remove CREST Nursing Home from Immediate Jeopardy. All aforementioned steps will be completed by corporate staff or under corporate supervision. Findings include: The facility abuse prevention program failed to protect three residents from financial deprivation, mental abuse and involuntary isolation. Resident #1 was identified as being inappropriately discharged and subjected to mental abuse. The resident was promptly discharged on the day of a scheduled surgery. A demand bill was given to the resident and the resident was asked to withdraw money from an ATM machine prior to surgery and pay the bill. The resident was told he was not welcome back at the facility after surgery and he was told to pack his belongings and take them with him to surgery. The resident was not advised of his rights to appeal the discharge, and was not provided contact information for the state Ombudsman or mental health advocacy. Cross reference tag F223. Resident#2 was identified as being subjected to mental abuse, involuntary seclusion and deprivation of personal funds. Interviews and record reviews substantiated the resident was pushed or assisted out to the parking lot where he was told he could come back into the facility after he calmed down. The resident deposited money in a personal funds account which was held by the facility. The facility denied the resident access to the money due to money owed to the facility. The resident was identified in a previous complaint survey ending on 10/30/14 at an immediate jeopardy level for isolation and mental abuse. Cross reference tag F 223 and complaint survey ending 10/30/14. Resident #3 had been identified as being subjected to mental abuse and financial deprivation due to inappropriate use/misuse of alcohol in the community. The facility restricted his personal funds in an attempt to modify his behavior. The resident denied having an agreement with the facility to restrict his actions and personal funds. Cross reference tag F 223. The facility's QAA committee failed to effectively identify quality deficiencies and develop plans of action including monitoring the effect of implemented changes and making needed revisions to the action plan. Cross reference tags F 223, 225, 226, 490 and 493.

br>Based on record review and interview, the facility failed to effectively train staff to identify and report abuse, and failed to identify an avenue for staff to report abuse above the facility level if necessary for 2 (#s 2, and 3) of 4 sampled residents. IMMEDIATE JEOPARDY RELATED TO THE CARE OF RESIDENTS On 4/30/15 at 6:10 p.m., the administrator, DON, and a Corporate staff member, were notified by the survey team of an immediate jeopardy situation that existed in the areas of Resident Behaviors and Facility Practices and Administration. A total of six IJ citations were cited. PLAN TO REMOVE THE IMMEDIATE JEOPARDY The plan to remove the Immediate Jeopardy was verified onsite on 5/01/15 at 5:04 p.m. After the immediacy was removed, the scope and severity remained at a level of H. The facility's plan to resolve the immediacy reflected: 1. (Social Services Director) shall interview all Residents or Resident legal agents (with a trust account) to determine if other residents have perceived or experienced limited access to Resident funds. 2. All staff shall be educated, by staff member B, corporate, beginning immediately, on the facility Resident Safety Position Statement (abuse policy) which includes abuse prohibition, definition of abuse, staff responsibility to immediately report all allegations and protect residents from further abuse, and other elements required by law. Staff B, corporate, and staff member N, Regional Director, will do training for the Administrator, DON, and management Staff to include the Office Manager, Business Office Assistant, MDS Nurse and Dietary Manager beginning on 4/30/15 and will be completed by 5/1/15. 3. All staff shall be counseled as appropriate for failure to identify and report allegations of abuse in accordance with policy and regulation beginning 4/30/15. All staff shall be trained prior to working the next scheduled shift. All counseling will be completed by 5/1/15. 4. Facility staff shall be educated on the facility chain of command. In the absence of the Nursing Home Administrator and Director of Nurses, a staff member must be designated to oversee the operation of the facility during the administrator's absence. Additionally in the absence Nursing Home Administrator and Director of Nurses, the phone number to the Regional Director of Operations will be provided to staff. Abuse and Neglect Policy and Procedure/Chain of Command Education: A. Who to call or report to in specific situation in which the supervisor is accused. a. Nurse b. DON c. Administrator B. Chain of command reporting procedures d. Supervisor > Charge Nurse > DON > NHA > Corporate Office i. Department managers will receive numbers to the corporate office also posted on bulletin boards for employees. 5. Corporate Staff shall provide education on identifying at risk residents for abuse, in accordance with facility Resident Safety Policy. All staff shall be trained starting 4/30/15 and will be completed prior to the individual's next shift. The date, content, time and who attended the training will be available for the state agency. The training shall include the policy requirement for staff members who observe abuse to immediately intervene and separate/remove involved residents from the situation. °Characteristics of the resident population including but not limited to: °Residents with a history of aggressive behavior °Residents who have behaviors which might precipitate resident-to- resident abuse of any kind °Residents with self-injurious behaviors °Residents who have behaviors related to psychological or medical problems °Residents with communication disorders °Residents who require extensive nursing care °Residents who are totally dependent on staff 6. The facility will immediately forward all allegations of abuse to the regional director and/or VPO for review and consultation. The facility shall receive guidance on the investigation focus and content to ensure resident safety is assured and that a reasonable level of information obtained for the facility to determine appropriate interventions to prevent a reoccurrence of a similar event. Training will be conducted on and during the investigation process. Investigations shall remain on file. 7. The executive QAPI committee will review and identify facility system failures identified in the survey, policy implementation, and develop and implement a corrective action plan. Monitoring will be conducted no less than once per month by the management company via a review of QAPI minutes times 3 months. 8. All residents will have access to Resident trust monies without limitation unless restricted by the legal Resident agent or by regulation. 9. All resident trust funds shall be managed in accordance with applicable State and Federal regulation. 10. All residents shall receive discharge notices as required by regulation prior to discharge. 11. Resident #2's trust account monies (the $800.03) will be issued to him May, 2015. Resident #2 will also receive a statement. 12. Staff member A was counseled on 4/30/15. Written warning: given by staff member V, VP of Operations; Name of Employee: Staff member A, administration; regarding: 1: Resident Trust Management 2: Documentation 3: Allegation of abuse and neglect 4: Discharge notice To avoid further discipline, employee should follow all regulations of company and resident rights, monitor residents in parking lot, document behavior care plans with IDT. Report all allegations to supervisor. Manage funds per regulation. 13. The facility investigation into this matter is ongoing. 14. NHA and DON remain on desk duty with no resident contact until investigation concluded. 15. Corporate staff will complete monthly interviews with department manager times 3 months to assure no complaints have been made against the administrator. Please find the following steps to remove CREST Nursing Home from Immediate Jeopardy. All aforementioned steps will be completed by corporate staff or under corporate supervision. The plan to abate the Immediate Jeopardy was verified onsite on 5/01/15 at 5:04 p.m. After the immediacy was removed, the scope and severity remained at a level of H. Findings include: During interviews between 4/27/15 and 5/01/15, conducted with staff, it was discovered a majority of management staff and nurses had knowledge of alleged abuses against residents #2 and #3. The interviews also showed: Resident #2 experienced alleged abuses in the areas of involuntary seclusion and deprivation of personal funds. Resident #3 experienced alleged abuse in the area of deprivation of funds. During an interview on 4/30/15 at 4:50 p.m., staff member A, administrator, stated he had received abuse training by staff member N, regional director, on approximately January 19th, 2015. He stated the training consisted of a paper review of the abuse policy. During the same interview, staff member A stated we have not had anything to report since I have been here that was suspicious. He further stated there was only one reported incident to the state agency and he did not feel it met criteria. The state agency identified through interview with facility staff that reports of alleged abuse against residents # 2, 3 and 4 were made with the human resources department at the corporate level, and through a human resources Hotline. The corporate staff failed to identify, investigate and respond to the reports of abuse. During an interview on 4/27/15 at 1:10 p.m., staff member G stated, while on the phone with corporate staff member W, she had reported resident #2 being pushed out the door by staff member A. Staff member W told her she would report that up. During an interview on 4/30/15 at 12:30 p.m., staff member G stated she reported the incident on 3/21/15 to corporate staff member W. During an interview on 4/27/15 at 1:15 p.m., staff member H stated she reported her concerns through the hot line. She said she reported issues with resident #s 2 and 4. During an interview on 4/30/15 at 2:45 p.m, a request was made to corporate staff member B for any investigations done for resident #s 1, 2, 3, and 4. During an interview on 4/30/15 at 3:25 p.m., corporate staff member B, stated if something was reported to the hotline, it would come to corporate staff member B or corporate staff member N, and they had not seen any reports. During an interview on 4/30/15 at 3:50 p.m., corporate staff member W, stated she did get statements that the administrator was rude to residents on 3/12/15. A release was sent to the corporate office on 5/4/15 requesting information regarding any reports of alleged abuse for residents # 1, 2, 3 and 4. As of 5/11/15, the state agency has not received the above information. During an interview on 4/30/15, at 4:40 p.m., staff member F, DON, stated, when asked who was in charge; I think it was the management team, I am not really sure who staff member A put in charge. Staff member F stated we had our cell phones with us with the expectation that any staff could call. She stated she told staff members J and X, RNs, that she and the administrator were leaving and had their phones. During an interview on 4/30/15 at 4:54 p.m., staff member A, administrator, stated there was not one specific individual appointed to be in charge of the facility when the administrator and DON were gone. He stated the nurse is in charge of the floor, and the department managers are in charge of their departments. A review of the Resident Safety Abuse Statement did not identify a contact person outside of the facility and did not identify a hot line as an avenue for reporting abuse. During an interview with a staff member who wished to remain anonymous, the staff member stated she had a fear of reprisal for reporting. On 5/1/15 at 11:45 a.m., corporate staff member B said if the employees call the hotline number, they need to say they are calling about an abuse report. The hotline is really just for HR purposes. Cross reference details of abuses in Tag F223

Based on interviews and record review, the facility failed to identify/report and investigate allegations of abuse for 2 (#s 2 and 3) of 4 sampled residents. This has the potential to affect all residents. IMMEDIATE JEOPARDY RELATED TO THE CARE OF RESIDENTS On 4/30/15 at 6:10 p.m., the administrator, DON, and a Corporate staff member, were notified by the survey team of an immediate jeopardy situation that existed in the areas of Resident Behaviors and Facility Practices and Administration. A total of six IJ citations were cited. PLAN TO REMOVE THE IMMEDIATE JEOPARDY The plan to remove the Immediate Jeopardy was verified onsite on 5/01/15 at 5:04 p.m. After the immediacy was removed, the scope and severity remained at a level of G. The facility's plan to resolve the immediacy reflected: 1. (Social Services Director) shall interview all Residents or Resident legal agents (with a trust account) to determine if other residents have perceived or experienced limited access to Resident funds. 2. All staff shall be educated, by staff member B, corporate, beginning immediately, on the facility Resident Safety Position Statement (abuse policy) which includes abuse prohibition, definition of abuse, staff responsibility to immediately report all allegations and protect residents from further abuse, and other elements required by law. Staff B, corporate, and staff member N, Regional Director, will do training for the Administrator, DON, and management Staff to include the Office Manager, Business Office Assistant, MDS Nurse and Dietary Manager beginning on 4/30/15 and will be completed by 5/1/15. 3. All staff shall be counseled as appropriate for failure to identify and report allegations of abuse in accordance with policy and regulation beginning 4/30/15. All staff shall be trained prior to working the next scheduled shift. All counseling will be completed by 5/1/15. 4. Facility staff shall be educated on the facility chain of command. In the absence of the Nursing Home Administrator and Director of Nurses, a staff member must be designated to oversee the operation of the facility during the administrator's absence. Additionally in the absence Nursing Home Administrator and Director of Nurses, the phone number to the Regional Director of Operations will be provided to staff. Abuse and Neglect Policy and Procedure/Chain of Command Education; A. Who to call or report to in specific situation in which the supervisor is accused. a. Nurse b. DON c. Administrator B. Chain of command reporting procedures d. Supervisor > Charge Nurse > DON > NHA > Corporate Office i. Department managers will receive numbers to the corporate office also posted on bulletin boards for employees. 5. Corporate Staff shall provide education on identifying at risk residents for abuse, in accordance with facility Resident Safety Policy. All staff shall be trained starting 4/30/15 and will be completed prior to the individual's next shift. The date, content, time and who attended the training will be available for the state agency. The training shall include the policy requirement for staff members who observe abuse to immediately intervene and separate/remove involved residents from the situation. °Characteristics of the resident population including but not limited to: °Residents with a history of aggressive behavior °Residents who have behaviors which might precipitate resident-to- resident abuse of any kind °Residents with self-injurious behaviors °Residents who have behaviors related to psychological or medical problems °Residents with communication disorders °Residents who require extensive nursing care °Residents who are totally dependent on staff 6. The facility will immediately forward all allegations of abuse to the regional director and/or VPO for review and consultation. The facility shall receive guidance on the investigation focus and content to ensure resident safety is assured and that a reasonable level of information obtained for the facility to determine appropriate interventions to prevent a reoccurrence of a similar event. Training will be conducted on and during the investigation process. Investigations shall remain on file. 7. The executive QAPI committee will review and identify facility system failures identified in the survey, policy implementation, and develop and implement a corrective action plan. Monitoring will be conducted no less than once per month by the management company via a review of QAPI minutes times 3 months. 8. All residents will have access to Resident trust monies without limitation unless restricted by the legal Resident agent or by regulation. 9. All resident trust funds shall be managed in accordance with applicable State and Federal regulation. 10. All residents shall receive discharge notices as required by regulation prior to discharge. 11. Resident #2's trust account monies (the $800.03) will be issued to him May, 2015. Resident #2 will also receive a statement. 12. Staff member A was counseled on 4/30/15. Written warning: given by staff member V, VP of Operations; Name of Employee: Staff member A, administration; regarding: 1: Resident Trust Management 2: Documentation 3: Allegation of abuse and neglect 4: Discharge notice To avoid further discipline, employee should follow all regulations of company and resident rights, monitor residents in parking lot, document behavior care plans with IDT. Report all allegations to supervisor. Manage funds per regulation. 13. The facility investigation into this matter is ongoing. 14. NHA and DON remain on desk duty with no resident contact until investigation concluded. 15. Corporate staff will complete monthly interviews with department manager times 3 months to assure no complaints have been made against the administrator. Please find the following steps to remove CREST Nursing Home from Immediate Jeopardy. All aforementioned steps will be completed by corporate staff or under corporate supervision. The plan to abate the Immediate Jeopardy was verified onsite on 5/01/15 at 5:04 p.m. After the immediacy was removed, the scope and severity remained at a level of H. Findings include: Review of the facility Resident Safety Abuse Statement reflected: Definitions: 1. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish willful means that the individual intended the action itself that he/she knew or should have known could cause physical harm, pain, or mental anguish. 5. Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation. 6. Involuntary seclusion is defined as separation of a resident from other residents or from his/her room, or confinement to his/her room, against the resident's will, or the will of the resident's legal representative. Emergency or short term monitored separation from other residents will not be considered involuntary seclusion and may be permitted if used for a limited period of time as a therapeutic intervention to reduce agitation until profession staff can develop a care plan to meet the resident's needs. 16. a. The supervisor on duty shall immediately safeguard the residents and immediately report all alleged violations involving mistreatment, neglect, or abuse . to the facility administrator. 16. c. The administrator shall also report all alleged violations to appropriate regulatory agencies per state statute and federal regulations. The Resident Safety Abuse Statement does not provide direction on how to report above the level of the administrator. 1. Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS, under B1000, dated 7/28/14, showed the resident had moderately impaired vision. Review of the nursing notes showed resident #2 had a cataract surgery on 3/04/15. While a resident in the facility, resident #2 experienced an alleged abuse on 3/16/15, that was known to the members of the interdisciplinary team. The facility and corporation failed to identify/report and investigate this allegation. The allegation stated the resident had been pushed into the parking lot and was told he could not come back into the facility until he calmed down. Refer to F223. During the month of March, resident #2 had deposited $800 dollars in the resident trust account and was then denied access to these funds. Resident #2 repeatedly voiced his objection to the facility keeping his personal funds as they were not intended to be used for payment to the facility. Interviews conducted through out the survey showed this situation was known to the interdisciplinary team, office staff, and nursing staff. The facility failed to identify/report and investigate this allegation. Refer to F223. 2. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care area assessment showed [DIAGNOSES REDACTED]. During the months of March and April of 2015, resident #3 was only able to get: 3/20/15 shopping $8.90; 3/24/15 personal $5.00; 3/27/15 personal $6.00; 4/01/15 snacks $2.58; 4/03/15 personal $5.00; 4/10/15 personal $5.60; and 4/23/15 shopping $1.79. Resident #3 voiced his objection to the facility keeping his funds, and requested funds be delivered to him. The facility failed to identify/report and investigate this allegation. The allegation stated the facility refused to give resident #3 personal funds from his resident trust account in an attempt to modify his behaviors. Refer to F223. During an interview on 4/30/15 at 11:40 a.m., corporate staff member B, stated she heard about the incident of resident #2 going outside with staff member A, administrator, when she arrived at the facility on 4/29/15. She was unable to remember who told her. During an interview on 4/30/15 at 11:40 a.m., corporate staff member B, stated all employee hotline calls are reviewed by the HR department at the corporate office. The HR department will then pass them on to regional director and vice president of operations. A request on 4/30/15 at 11:40 a.m. was made for all corporate investigations of allegations of abuse against residents #1, 2, 3 and 4, due to reports by staff having reported directly and anonymously to staff member W, corporate HR. These documents were not provided to the State Agency. During an interview on 4/30/15 at 12:03 p.m., staff member N, regional director stated, he was not aware of any abuse allegations concerning resident #3. Allegations and mistreatment would be handled in the facility. He further stated there was a hotline available. During an interview on 4/30/15 at 12:03 p.m., with corporate staff member B, and corporate staff member N (who was on the phone). Staff member N said, I am not aware of any specific abuse allegations of residents #s 1, 2, 3, or 4. Allegations of mistreatment would be handled in the facility and would involve the administrator. During an incident a week ago, they responded to an audit looking at resident trust accounts. Staff member N stated there were no reports of allegations of misappropriation of funds. The nature of the complaint was anonymous. Again he stated he had not received any allegations of abuse for residents # 1, 2, 3, or 4. After receiving an anonymous complaint, the allegation regarding resident trust funds was not investigated by the facility or corporate office. On 4/30/15 at 1:30 p.m., the State Agency verified there was an ongoing investigation with another state agency regarding misappropriation of residents' funds. During an interview on 4/30/15 at 3:50 p.m., corporate staff W, HR, stated if an employee has an issue they wish to report they can use the hotline. The hotline would summarize the phone call and send it to corporate staff member W. If it is an anonymous it is forwarded to the RO and the nurse director, if it is not anonymous she would call the complainant for more information. Corporate staff member W further stated she did get statements that the administrator was rude to residents on 3/12/15. Staff member W further stated if it was anonymous, the complaint might not get investigated. During an interview on 4/30/15 at 4:50 p.m., staff member A, administrator, stated he was the abuse coordinator for the facility. Staff member A also stated one incident had been reported to the state agency, but he did not feel it met the criteria for reporting. Staff member A also said there had not been anything that was suspicious to report to the state agency since he had been at the facility. On 5/1/15 at 11:45 a.m., corporate staff member B said if the employees call the hotline number they need to say this is an abuse report. The hotline is really just for HR purposes. Review of the Resident Safety Abuse Statement did not direct staff to call the hotline for incidents of abuse. During interviews throughout the survey, reports were made of staff knowledge of resident abuse, either directly or indirectly. During interviews with the IDT team to including the DON, social services, activities, physical therapy, maintenance, MDS coordinator and the dietary manager, it was reported that all members had some knowledge of residents #s 2 and 3 alleged abuses. The facility or corporate office did not investigate the alleged abuses of residents #s 2 and 3. During an interview on 5/1/15 at 12:09 p.m., corporate staff members N and B, stated there was currently an ongoing investigation of abuse of resident trust funds being performed by an outside state agency. This complaint was triggered by an anonymous complainant. This audit was known at the corporate level and was not forwarded to the appropriate state agency. During a meeting on 4/30/15 at 6:10 p.m., and again at 6:46 p.m., the state agency notified the facility and corporate staff of an immediate jeopardy in the areas of abuse of resident behaviors and facility practices and administration. Specific abuses identified were mental abuse, involuntary seclusion and deprivation of resident trust funds for residents #1, 2 and 3.

Based on observation, interviews and record review, the facility lacked effective administration for 16 sampled residents. These residents were identified as being affected by deficient practice during the survey. In addition, serious deficiencies were cited. Findings include: Immediate Jeopardy was identified for 6 residents, #s1, 2, 9, 10, 11 and 16 of 16 sampled residents for failure to protect from abuse and failure to provide wound care. 1. Protection from Abuse - The facility failed to protect resident #1 from sexual, physical and verbal abuse. Scope and severity was widespread with potential for more than minimal harm. Cross Reference Tag F223. 2. Failure to Report and Investigate Abuse and Failure to Screen Employees for Past History of Abuse - The facility failed to ensure staff were currently licensed as nurses. The facility failed to perform background checks on employees prior to those employees providing resident care. The scope and severity was widespread with immediate jeopardy. Cross reference Tag F225. 3. Failure to Develop and Implement Policies to Prevent Abuse - The facility failed to report timely and investigate allegations of abuse for resident #1. The scope and severity was widespread with immediate jeopardy. Cross reference Tag F226. 4. Failure to Maintain Professional Standards - The facility failed to ensure professional standards were followed for residents #s 8, 9, 10 and 11. The scope and severity was widespread with immediate jeopardy. Cross reference Tag F281. 5. Quality of Care - The facility failed to provide the necessary care and services to attain the highest level of well being for resident #s 9, 10 and 11. The scope and severity was a pattern with immediate jeopardy. Cross reference Tag F309.

Based on record review and interviews, the facility failed to conduct thorough investigations of staff prior to hiring, for five employees. The facility failed to immediately report alleged abuse to the State Agency within 24 hours for 4 (#'s 1, 2, 9 and 16) of 16 sampled residents. The facility failed to have evidence that alleged violations were thoroughly investigated and a 5 day follow-up was sent to the State Agency for 3 (#'s 1, 14 and 15) residents. The facility failed to take appropriate action for one staff accused of suspected abuse. These failures have the potential to affect all residents in the facility. An Immediate Jeopardy was called on 10/29/14 at 1:30 p.m. Specific Failures were: 1. The facility failed to thoroughly investigate employees through background checks prior to hiring. 2. The facility failed to immediately report (within 24 hours) to the State Agency alleged abuse violations. 3. The facility failed to conduct thorough investigations of employees and allowed them to have contact with residents after being suspected of resident abuse. Plan to Abate Immediate Jeopardy: 8. Corporate staff or designee shall provide education on identifying at risk residents for abuse in accordance with facility Resident Safety Policy. All staff shall be immediately trained, starting 10/30/14, to redirect residents with wandering behaviors, note the behaviors on the assignment sheets, and report to the nurse. The date, content, time and who attended the training will be available to the State Agency. The training shall include policy requirement for staff members who observe abuse to immediately intervene and separate/remove involved residents from the situation. Staffing levels are assessed on a continuing basis. Adjustments to staffing levels are based on the average census of each unit as well as the individual needs of the residents. 9. The facility will immediately forward all allegations of abuse to the regional director and/or VPO for review and consultation. The facility shall receive guidance on the investigation focus and content to ensure resident safety is assured and that a reasonable level of information is obtained for the facility to determine appropriate interventions to prevent a reoccurrence of a similar event. Training will be conducted on and during the investigation process. Investigations shall remain on file. 10. The Executive QAPI committee will review the facility process for reviewing staff qualifications certifications, and licensure in accordance with law, 10/30/14 and one time per week for three months. 14. (Staff member G) was removed from the floor upon learning of her licensure status. No licensed staff will be employed without verification of licensure. The active/current licensure status of all nurses is verified 10/29/14. Staff member G will be reported to the licensure board for failure to maintain a MT license 10/30/14. Facility administration (staff members A and R) were immediately in-serviced on policies and procedures for new staff screening 10/29/14 by (staff member F), RDO. 15. The facility HR rep was verbally counseled 10/29/14 by (staff member F), RDO for failure to screen (staff member G) and follow established policy and procedure. Background checks shall be immediately completed in accordance with law. The Executive QAPI committee will review the facility process for reviewing all staff qualifications, licensure and certification in accordance with law, 10/30/14 and one time per week for three months. The correction plan was accepted and the immediate jeopardy was abated on 10/30/14 at 9:50 p.m. The deficient practice remained at the scope and severity of an I once the immediate jeopardy was abated. Findings include: 1. A review of the Resident Safety Abuse Statement (see F226); and a review of the Resident Rights Under Federal Law document provided by the facility reflected: 28. The Resident has the right to be free from verbal, sexual, physical, or mental abuse... 2. A review of facility staff personal records showed: a. Staff member G, LPN, was hired by the facility on 2/4/14 with a background check completed on 2/11/14. The record was reviewed and lacked a current nursing license. In an interview on 10/28/14 at 4:00 p.m. s staff member B, DON, was asked to provide a current Licensed Practical Nurse license for staff member G. Staff member B, stated staff member G told her she had applied for a Montana license and sent them a check, so she thought she had a license. The facility and surveyors looked online at the Montana State Licensee Lookup and found a license for staff member G that was terminated in 2001 from Georgia. Staff member B was notified of the lack of licensure for staff member G and asked to remove her from her nursing duties at 5:00 p.m. on 10/28/14. Staff member B immediately spoke with staff member G and informed her she could not work as a nurse without a nursing license. During an observation on 10/28/14 at 5:15 p.m., staff member G was at the medication cart, unsupervised. The DON was notified that staff member G had been in the medication cart. Staff member B, DON, stated "Well, they have to count narcotics before she can leave." Staff member B was again informed that staff member G did not have a license and was not able to practice nursing. Staff member B again asked staff member G to leave the building. Staff member G left the building at 5:30 p.m. b. Staff member H, CNA, had a hire date of 5/20/14 with a background check completed on 7/8/14. c. Staff member I, RN, had a hire date of 5/27/14 with a background check completed on 7/8/14. d. Staff member J, RN, had a hire date of 2/15/13 with a background check completed on 3/20/13. e. Staff member L, CNA had a hire date of 7/22/14 with a background check completed on 8/14/14. In an interview on 10/28/14 at 3:04 p.m., staff member R, accounts payable, stated background checks are usually done within one week of hire and licenses and certifications are looked up online prior to working. 3. Review of Reportable Incidents sent to the State Agency showed: a. The date of an alleged incident on 2/27/14 was reported to the State Agency on 3/4/14. b. The date of an alleged incident on 4/25/14 was reported to the State Agency on 4/29/14. c. The date of an alleged incident on 7/14/14 was reported to the State Agency on 7/17/14. The facility failed to complete a thorough 5 day investigation of the incident. Review of an incident dated 7/24/14 showed the facility documented counseling for staff member H, CNA in regards to the appropriate way to check for incontinence and how to talk to the resident during cares. Staff member H's personnel file was reviewed and the documentation for the above mentioned counseling was not found. During an interview on 10/28/14 at 3:30 p.m., staff member B, DON, stated, "If the employee is counseled by me the documentation would be found in the employee personnel file. I would make the decision whether to counsel the employee or not." d. The date of alleged incident on 8/1/14 was reported to the State Agency on 8/5/14. e. The date of alleged incident on 8/23/14 was reported to the State Agency on 8/26/14. The facility failed to complete a thorough 5 day investigation of the incident. f. The date of an alleged incident on 9/20/14 was reported to the State Agency on 9/24/14. "Initial 24 Hour Report: On 9/24/14 (resident name) states (staff member G), was inappropriate, 'bullying' (resident #1)." 5 Day Investigation Results Report: "Outcome of your investigation: After interviewing a number of staff, including, CNAs and nursing, along with resident's (sic) of the floor (staff member G) worked, it was decided to have her return to work, but, to another wing of the building. Resident in question, (resident #1), could not give any specific details, but, did not want that particular nurse, to give her medications or treatments. (Staff member G) will be evaluated, week to week for the next 60 days by the Director of Nursing, as to how she is dealing with the residents of the new wing. This includes visiting with those residents of the area she is working in." An review of the Investigation notes provided by the facility showed, An undated review of a statement written by a staff member, "(CNA) stated that (staff member G) said to (resident #1) 'If you don't behave you will end up going back to live with your sister who abused you.' CNA was coming out of a room [ROOM NUMBER] doors down when she heard this." An undated review of an interview with (resident #2), "(Resident #2) spoke with DON and SS regarding a complaint she wanted to make regarding (staff member G). (Resident #2) states that on Saturday 9/20/14 at approximately 2200 (10:00 p.m.) she overheard (staff member G) asking (resident #1) why she was not in bed. She then said 'go to the bathroom you big baby' and 'quite (sic) crying and do as you are told or you are going to your sisters.' (Resident #2) stated that she heard (resident #1) crying and stating 'I'll run away.' (Staff member G) then responded 'I will help you so you could get splattered all over the road.' (Resident #2) then stated that on Sunday 9/21/14 she also heard (staff member G) calling (resident #1) stupid and stating 'You can't do anything for yourself.' " Review of hand written interviews conducted with residents lacked the identity of the writer and reflected, Saturday night 10 p.m. - (per resident #2): "(Resident #1) why aren't you in bed?" "Go to the bathroom you big baby" "Quite (sic) crying or you'll go to your sisters" (Resident #1) "I'll run away" Sunday per (resident name) (Staff member G) "you can't do anything for your self" to (resident #1). "She takes my jerky and wings and owes me $5 for the wings," referring to (staff member G). (Resident #9) "She cannot give names currently, states (staff member G) sends residents to there (sic) rooms. She doesn't use gloves and doesn't sanitize her hands then picks at an incision. She pulled a stitch out without gloves." (Resident #16) stated "Staff member G told me that I play w/ my poop or stool and that's a lie. She said it in the hall in front of other people." On 9/24/14 a verbal Employee Warning dated reflected: "Violation of resident rights and unprofessional conduct". The form states that staff member G was previously warned on 9/15/14 at 1415 (2:15 p.m.). On 9/24/14 a written warning reflected: "Violating Infection Control Policy." Both forms were signed by the DON and dated 9/24/14. A review of a hand written, unsigned, document dated 9/20/14 showed: "(Resident #2) asked for her night meds and pain pill, vallume (sic) and the nurse (staff member G) refused to give her those meds. She said that she was too sleepy and that she could have Tylenol. (Resident #2) asked nurse if she would go down and change her dressing, and the nurse said that (resident #2) can wait till she got down that way, that she was last on her list. (Staff member G) told (resident #2) if she couldn't behave that she would end up going back to live with her sister who abused her. (Staff member G) told (resident #16) that he could not come out of his room because he played with his stool and that he most likely would never go home. "So many residents have complaints about her on the NW (northwest) wing. There are certain residents that don't like her and she knows they don't. It seems like she purposely goes in and gets them adgitated (sic) and upset." Additionally on 9/21/14 the above document was amended to include the following: "@ (at) 3:30 (resident #2) was talking to me, she thinks that (staff member G) is refusing to go in her room cause she owes her money. (Resident #2) said that on Wednesday she and (staff member G) went in on hot wings together and (staff member G) was going to pay her back and hasn't yet. (Resident #2) also said (staff member G) goes in there all the time and helps herself to (resident #2's) snacks." A review of a hand written document by staff member T, RN, addressed to the DON reflected: "On Thursday night, (staff member G) told (staff name, LPN) that they did not need no (sic) count because she counted at 1900 with (staff name). I explained that she did need to count again. Staff member G slammed book down and shouted 'OK' (staff name). I told her she needed to step back and count to 10. There was staff and residents present at the time." Staff member T signed the document. A review of a hand written document dated 9/22/14 and signed by staff member M, LPN reflected: "I was told by (resident #9) that (staff member G), the afternoon shift nurse, was picking at her lower leg where she had a biopsy taken a few days earlier. The concern is that the resident stated that (staff member G) was picking at her left leg with her fingernails and picking at the scab with her bare hands. She was not wearing gloves at this time. (Resident #9) also stated that the nurse was not cleansing the IV picc (sic) line with antiseptic wipes before introducing the antibiotic to the lumen, resident stated she also did not see gloves on the nurse. (Resident #9) is asking to talk with (staff member B) about this situation." No documentation regarding any discussion was provided to the surveyor prior to the exit. Review of a summary dated 9/26/14 by staff member A, read, "I visited with (staff member G, LPN), regarding a complaint from a resident who overheard (staff member G) talking derogatory to (resident #1), as to why she was not going to bed in a demeaning manor (sic). Also present were (sic) (CNA name), who served as a witness to the conversation and the DON. I read a quote from a witness to the conversation 'Go to the bathroom you big baby. Quit crying and do as you are told or you are going to your sisters. I'll help you so you can get splattered all over the road." (Staff member G) denied she made those type of comments. 'I never called anyone a baby.' I read another quote from a co-worker regarding another resident (#16). 'You are not to come out of the room because you play with your poop and you will never go home.' (Staff member G) said she did say something to that manor (sic). 'She said she was trying to make (resident #16) understand his situation with his needing to stay in his room at the time due to infection control with [MEDICAL CONDITION].' I asked her why she would make these type of comments to the residents who need our care. She said she knows she is loud and needs to keep it down. I expressed the fact (that) these type(s) of statements can be harmful to the residents and be severe enough to go against her license and her employment. (Staff member G) has a rough approach even though she is smiling all the time. We also discussed her becoming upset with a nurse in counting end of shift narcotics a week ago. She said she did not get upset and knows the importance of counting narcotics. (Staff member B), DON, felt people do become upset about (staff member G) and may mis-interpit (sic) her statements. I asked (staff member G) if she had anything to say about this matter. 'She said she never intended to hurt anyone's feelings and knows better how to present herself while working on the floor.' I told (staff member G) we ((staff member B) and myself (staff member A)) would be discussing the matter and get back to her as to our decision. Following the meeting, (staff member B) feels she like (sic) to keep her on the floor. She knows (staff member G) now understands what she needs to do to present herself in front of the residents and coworkers. I said if we keep (staff member G), she would not be working the same wing again, unless, it is necessary. I asked (staff member B) to discuss the matter of (staff name) with the other nurses before we decide what to do." The facility did not provide any additional information regarding the final decision to allow staff member G to resume working with the residents prior to the exit. During a conference on 10/20/14 at 8:30 p.m., staff member F, Regional Director of Operations, stated all investigations are reviewed at the corporate level. "d. Initial 24 Hour Report On 10/25/14 at 4 am in the morning the Nursing Assistant was doing her rounds and came across resident #4 standing over resident #1 in her recliner. Resident #1 prefers to sleep in her recliner. The aide asked him what he was doing and she noticed resident #1's nightgown up and it appeared he was touching her private area. She told him to get out of resident #1's room and she immediately got the supervisor and they called the police. Nursing stayed with resident #1 and evaluated her and then resident #4 was taken into custody by the Police. Resident #1 was sent to the emergency room for further evaluation." 5 Day Investigation Results Report: (No date on document and the resident name was hand written, the report was hand delivered to surveyors on 10/30/14). "Outcome of your investigation: (Resident #1) continues to visit with other residents, attend social gatherings and has appeared to be as before the incident. (Resident #1) does state she knew (resident #4) prior to being at (facility name). (Resident #1) states he was a 'Boyfriend.' Social Services had CRT (Crisis Relief Counselor) come and visit with (resident #1) and the disposition states she does not appear to be at risk for self harm and is recommended she be monitored more at night. Discussed with Administrator and hourly checks are to begin this evening. (Resident #1) also has a (sic) appt. with her Psychiatrist at (facility name) next week. We are encouraging (resident #1) to move in with another roommate for more company. The outcome of the incident is still underway with the local Police Department." Review of the Nursing Progress Notes dated 10/25/14 at 6:15 a.m., for resident #1 reflected "Pt (patient) was resting in recliner w/eyes closed. CNA was doing rounds @ 0400 (4:00 a.m.) and found this resident in pt's room fingering her. CNA reported that she asked the resident what he was doing and he stated, 'I don't know, playing with her I guess.' CNA immediately came to get me and I went to the pt's room to ask her what happened. In pt's own words, 'I don't want him in here. I'm scared. Keep him out. He put his finger in my privates and touched my breast.' I examined the pt's perineal area and there is minor redness around the area but no evidence of swelling, bleeding, or lacerations. Area is intact. I sat with the pt and listened to her repeat what happened several times. Pt reported that she told him to stop but he did not stop. Police, facility administrator, and DON were immediately notified 0430..." A review of the emergency room evaluation dated 10/24/14 at 11:35 a.m. read, "Chief Complaint Patient presents with alleged sexual assault. HPI (resident name) is a 58 yr (year) female who present with complaint of a sexual assault. The patient resides in a local nursing home and awoke to find him in her room and 'put his fingers in her privates'. The attacker apparently was found in the act by nurses at the nursing home and has confessed to authorities. The patient denies any penile or oral contact other than saying that he tried to kiss her. Physical Exam GU ([MEDICAL CONDITION]) External exam shows 2 vertical areas of excoriation on the inner aspect of the labia minora at the 12:00 position which are consistent with nonaccidental abrasions...another area of excoriation at about the 9 to 10:00 position was visible. Speculum exam revealed areas of abrasion on the roof of the 1st part of the vaginal vault (12:00 position) and as well as another area of abrasion at the 6 to 7:00 position. ED Course & Medical Decision Making The patient was told there were findings on exam consistent with her allegations. Photographs were obtained and other evidence collected by the nurse. Final Impression 1. Sexual assault" On 10/27/14 at 1:06 p.m., in the Nursing Progress Notes: Follow Up of Incident: Other: ER visit for exam of possible assault. Physician Review: [DIAGNOSES REDACTED]. Injury: No apparent injury. Actions: Reported to Primary physician (Dr. name). Review of Social Service notes dated 10/28/14 at 11:08 a.m. reflected, "Late entry from yesterday; visited with (resident #1) and asked if she would like to visit with someone regarding Saturday's event and she stated that she wanted to talk with this writer and proceeded to be very happy and excited to talk about her 'Boyfriend in room [ROOM NUMBER].' (Resident #1 ) also mentioned her old boyfriend was in room [ROOM NUMBER]. (Resident #1) finally agreed to visit with a CRT (Crisis Relief Counselor)." Review of Social Service notes dated 10/29/14 at 7:49 p.m. reflected, "Referred to the northwest nurse that hourly check should begin this evening, beginning at 8pm until daylight. Also was to be noted on the CNA's sheets. Asked nurse (name) to have staff keep a log for now; until we see what corporate wishes. Note: The incident happened on 10/25/14 (4 days earlier)." During a telephone interview on 10/30/14 at 5:00 p.m. staff member D, CNA, stated she was starting to do rounds at approximately 4:00 a.m. She stated she usually starts at the end of the hallway where resident #1's room is located. Resident #1 was sleeping in her chair (a recliner), so she went to help another resident. When she came back to resident #1's room approximately 20-25 minutes later she observed resident #4 bending over resident #1 with his hand moving back and forth very forceful and rough. It looked like his fingers were inside resident #1. When she asked resident #4, "what are you doing?" he stepped back and held up his hands and stated "playing were her I guess". Staff member D stated she immediately got the nurse. Resident #1 was saying "I scared, he touched privates, I scared." Staff member D stated that resident #4 had been awake and wandering all night long, and that he had consumed three mountain dews and four sandwiches. Staff member D stated that resident #1 required female care only, and the other two CNA's on shift with her were male. The other residents would complain about one of the male CNA's and did not want him to provide care for them. She also stated that there were multiple other residents who preferred female care only. A review of Resident #1's MDS with an ARD 6/23/14, showed a BIMS score of 9, and on 9/14/14 the BIMS score was 2. According the the RAI a score of 2 shows severe impairment and a score 9 is moderately impaired. A review of the above dates of the MDS documentation for ADL's for resident #1 reflected she needed extensive assist with all ADL's, except eating. Review of resident #1's Care Plan dated 6/24/14, did not identify resident #1 having behaviors regarding boyfriends. During an interview on 10/30/14 at 12:30 p.m., resident #1 was sitting in her wheelchair watching TV as she started to talk, she immediately moved from one subject to another. She stated she got her foot caught in the door, then stated, "Joe comes in my room, we talk and watch TV, he comes in here all the time. I love Joe, Joe loves me, He pushed me out of room, down hallway to take medicine. I sleep in chair - love my chair. My sister has 20 kids and she doesn't have time for me. I am on my own. I only have Joe, he loves me. I love Butte, Butte is my town. My birthday is November 19th. I have big party. I like rain, I like to swim. My sister took my clothes. I don't know why. I wear diaper. I put them on by myself. I like my chair, it has a pillow in it. My sister took my coat." When asked her if anyone came in her room she started repeating phrases of the above conversation. During an interview on 10/30/14 at 1:10 p.m., staff member I, RN, stated she does not feel that resident #1 can make a competent decision. Staff member C, stated that after an investigation is completed, the Administrator, DON, and Social Services get together so they can be notified of the outcome of the investigation. If it is a staff to resident incident, Social Services and the DON would get together after the investigation has been completed. Staff member C stated, "staff member B has the final say over staff."

Based on record review and interview, the facility failed to implement all seven components of the abuse policy including screening of all hires, orientation and ongoing abuse training, care and treatment of [REDACTED]. An Immediate Jeopardy was called on 10/29/14 at 1:30 p.m. Specific Failures Were: 1. The facility failed to screen employees for licensure/certification and background checks prior to working with residents. 2. The facility failed to provide ongoing education for staff in abuse prohibition practices after suspected abuse had occurred. 3. The facility failed to prevent abuse by staffing and each shift in sufficient numbers to meet the needs of the residents and failed to assure staffing assigned have knowledge of the individual residents' care needs. The facility failed to supervise and identify appropriate behavior of staff. 4. The facility failed to follow the facility policy and procedures for abuse/neglect and investigations. 5. The facility failed to protect residents from harm during an investigation. -The facility failed to protect residents from harm during the investigation; and -The facility failed to follow their policies on reporting alleged violations to the state. Plan to Abate Immediate Jeopardy: "1. (Resident #4) was immediately removed from the room and was under police observation until he was removed from the facility. The situation was immediately abated. The resident was assessed by the nurse and interviewed by the police. The resident was evaluated at the emergency room . The facility, with the assistance and guidance of Real Property Health staff will interview (resident #1) and attempt to define her perception of the word 'boyfriend.' Care plan changes may be made in consultation with the resident, her family and physician, that are consistent with the needs and preferences of the resident and facility assessment. The facility will monitor her emotional state through daily interaction and nursing assessment and documented in the nurses notes. 2. The facility interdisciplanary (sic) team will meet 10/30/14 and begin plans for an appropriate roommate, beginning 10/30/14, and implement as soon as possible for (resident #1) so the resident will not be alone. A suitable roommate shall be located through trial. Efforts will be made to locate a roommate with similar interests and daily patterns/habits. The facility will consider the location of the resident's room in proximity to the nurses station as a possible intervention. 3. (Staff member C) interviewed all interviewable residents. The list of the interviewed residents and how she determined who to interview will be provided to the department by 10/30/14. 8. Corporate staff or designee shall provide education on identifying at risk residents for abuse, in accordance with facility Resident Safety Policy. All staff shall be immediately trained, starting 10/30/14, to redirect residents with wandering behaviors, note the behaviors on the assignment sheets, and report to the nurse. The date, content, time and who attended the training will be available for the state agency. The training shall include the policy requirement for staff members who observe abuse to immediately intervene and separate/remove involved residents from the situation. Staffing levels are assessed on a continuing basis. Adjustments to staffing levels are based on the average census of each unit as well as the individual needs of the residents. 9. The facility will immediately forward all allegations of abuse to the regional director and/or VPO for review and consultation. The facility shall receive guidance on the investigation focus and content to ensure resident safety is assured and that a reasonable level of information is obtained for the facility to determine appropriate interventions to prevent a reoccurrence of a similar event. Training will be conducted on and during the investigation process. Investigations shall remain on file. 10. The Executive QAPI committee will review the facility process for reviewing staff qualifications certifications, and licensure in accordance with law, 10/30/14 and one time per week for three months. 14. (Staff member G) was removed from the floor upon learning of her licensure status. No licensed staff will be employed without verification of licensure. The active/current licensure status of all nurses is verified 10/29/14. (Staff member G) will be reported to the licensure board for failure to maintain a MT license 10/30/14. Facility administration staff (members A and R) were immediately inserviced on policies and procedures for new staff screening 10/29/14 by staff member F, RDO. 15. The facility HR rep was verbally counseled 10/29/14 by (staff member F), RDO for failure to screen (staff member G) and follow established policy and procedure. Background checks shall be immediately completed in accordance with law. The Executive QAPI committee will review the facility process for reviewing all staff qualifications, licensure and certification in accordance with law, 10/30/14 and one time per week for three months." The correction plan was accepted and the immediate jeopardy was abated on 10/30/14 at 9:50 p.m. The deficient practice remained at the scope and severity of an I once the immediate jeopardy was abated. Findings Include: 1. A review of the Resident Safety Abuse Statement reflected the following: Purpose: It is the policy of our facility to maintain a work and living environment that is professional and free from threat and/or occurrence of harassment, abuse (verbal, physical, mental or sexual), neglect, corporal punishment, involuntary seclusion and misappropriation of property. Providing a safe environment for the resident is one of the most basic and essential duties of the facility. Employees have a unique position of trust with vulnerable residents. Having access to private information, being in a physically intrusive position and having elevated status and special relationships with residents, make ethical and professional behavior essential. Our facility promotes an atmosphere of sharing with residents and staff without fear of retribution. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. This system cannot guarantee that abuse will never occur. It can only assure that the facility is doing all that is within its control to prevent occurrences. Protocol: Definitions: 1. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm or pain or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that necessary to attain or maintain physical, mental and psychosocial well-being. This presumes that instances of abuse of all resident, event those in a coma, cause physical harm or pain or mental anguish. (Note that this federal definition of abuse indicates that the act needs to be "willful" and that it needs to have resulted in physical or psychosocial harm to the resident or would be expected to have cause harm to a "reasonable person" if the resident cannot provide a response. "Willful means that the individual intended the action itself that he/she knew or should have known could cause physical harm, pain or mental anguish. Even though a resident may have a cognitive impairment, he/she could still commit a willful act.) 2. Verbal Abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. 3. Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. 4. Physical Abuse includes, but is not limited to, hitting, slapping, pinching or kicking. It also includes controlling behavior through corporal punishment. 5. Mental Abuse includes but is not limited to, humiliation, harassment, and threats of punishment or deprivation. 6. Involuntary Seclusion is defined as separation of a resident from other resident or from his/her room or confinement to his/her room (with or without roommates) against the resident's will, or the will of the resident's legal representative. Emergency or short term monitored separation from other residents will not be considered involuntary seclusion and may be permitted if used for a limited period of time as a therapeutic intervention to reduce agitation until professional staff can develop a plan of care to meet the resident's needs. 7. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. 8. Misappropriation of Resident Property means the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 9. Injuries of Unknown Origin should be classified as such when both of the following conditions are met: (1) The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and, (2) The injury is suspicious because of the extent of the injury or the location of the injury (i.e., the injury is located in a area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. Application: 10. The Policy Regarding Resident Safety Has Application In the Manner in Which: a. Prospective employees are screened. b. New employees are oriented. c. On-going education is provided for all employees. d. The care and treatment of [REDACTED]. e. The staff members are supervised. f. The reporting, investigation, and appropriate response to any suspected and/or substantiated violation is completed. Procedures: 11. Employee Screening: a. All individuals considered for employment shall receive a reference check. All responses shall be documented. lithe reference sources shall be asked about job performance, skills, habits, and reliability. b. All employees shall have a criminal background check. i. Initial and any required future background checks will be conducted in accordance with applicable state and federal laws. Checks may include criminal history, state caregiver registry, OIG, and exclusion lists. The type, frequency, and timing of checks will be in accordance with applicable state and federal law. 12. New Employee Orientation: a. Each new employee shall be oriented to facility resident safety policies and procedures regarding the prevention, reporting and investigation process associated with resident safety. b. Each new employee shall be informed that violation of this Resident Safety Policy will not be tolerated and may be ground for immediate termination. c. Each new employee will be informed of their responsibility to immediately report any violation or alleged violations. Failure to do so will result in disciplinary action. 13. On-going Education: a. In-service programs shall be presented at new employee orientation and at least annually thereafter which will encompass: i. Identification, intervention, and reporting of situations in which abuse of mistreatment are likely to occur. ii. Characteristics of the resident population including but not limited to: 1. Residents with a history of aggressive behaviors. 2. Residents who have behaviors which might precipitate resident-to-resident abuse of any kind. 3. Residents with self-injurious behaviors. 4. Residents who have behaviors related to psychological or medical problems. 5. Residents with communication disorders. 6. Residents who require extensive nursing care. 7. Residents who are totally dependent on staff. iii. Training in appropriate interventions to deal with aggressive and/or inappropriate behaviors or reactions of residents. iv. The facility procedure for staff to report their knowledge of suspected violations of the resident safety policy without fear of reprisal. v. Training to recognize the signs of employee burnout, frustration and stress that may jeopardize resident safety. vi. Training on what constitutes violations of resident safety and misappropriation of resident property. 14. Care and treatment of [REDACTED]. a. Staffing levels are assessed on a continuing basis. Adjustments to staffing levels are based on the average census of each unit as well as the individual needs of the residents. b. Staff will be assigned to units based on a resident need and secondarily by staff preference. c. Residents and families are encouraged to report any observations or instances of resident behaviors that could result in a bruise (i.e. combativeness with cares, pinching a finger in a door, etc.) so if an injury develops, investigation staff will have a lead on probable cause and will also be able to assist with resident care plan revisions. e. Should a resident become hostile or unmanageable in any way that would jeopardize his/her safety or the safety of others, the licensed nurse my immediately implement the Unmanageable Residents Policy. f. Staff members who observe a resident to resident abuse situation will immediately intervene and separate/remove the involved residents from the situation. Nursing staff will notify other shifts of the incident so they may be alert for the possibility of additional incidents. Immediate interventions will be initiated to attempt to eliminate the likelihood that the situation could recur. The facility IDT team will care plan the resident/incident to discuss the situation and further develop possible approaches and interventions. If a resident's detrimental behavior persist, the IDT team will care plan the resident again and determine which corrective actions will need to be taken (i.e. psychological assessment, alternative placement, implementation of the Unmanageable Residents Policy, etc.) g. Facility social workers review residents' right with all residents and encourage communication of any problem or concern. h. Residents or families presenting concerns regarding any of these resident safety policies shall receive feedback as to the results of the investigation. 15. Supervision of Staff: a. It is the responsibility of all supervisors to supervise employees in a manner to improve their effectiveness in dealing with aggressive and/or inappropriate behaviors or reactions of residents and to ensure that needed care is provided in accordance with the care plan. b. Supervisors will, through training, education, communication and support, help staff recognize potentially stressful situations and understand how these situations can lead to inappropriate reactions to certain resident behaviors. c. Staff will be encouraged to let supervisors know when a resident is presenting a challenge to their own physical and/or mental well-being, and are encouraged to express their frustrations about any resident to their supervisor or charge nurse. 16. Reporting Suspected Violations: a. Any suspected, observed or reported violation of this resident safety policy or any observed unexplained injuries (i.e. injuries of unknown origin) to a resident will be reported to the supervisor and the DON and/or Administrator per facility policy immediately. b. The supervisor on duty shall IMMEDIATELY safeguard the resident(s) and report any alleged violations of this resident safety policy or observation of an unexplained injury to the DON and/or Administrator or designee. The DON or the designee will notify the Administrator if they are the first contact. c. The Administrator or designee shall determine if notification should be made to appropriate regulatory agencies (per state statute) or law enforcement agencies. Depending on the scope and severity of the incident, law enforcement may be called to immediately take over and direct the investigative process. In these situation, the Administrator or designee needs to direct staff to treat the area like a crime scene, and not contaminate or destroy any evidence (i.e. giving the resident a shower, washing clothes or bedding, throwing items away, etc.) 17. Procedure For Investigation: a. When appropriate, the Quality Assurance Manager and/or the supervisor on duty will assess the resident (including the size, location, etc, of any injury), and properly document the date, time, and location of the reported or suspected incident. There may be circumstances, such as sexual abuse, when a specifically-trained professional should be utilized if available (i.e. a SANE professional: Sexual Assault Nurse Examiner). b. Injuries of unknown origin will be thoroughly investigated, no matter how minor (i.e. small bruise, skin tear, etc.) to determine the cause or probable cause. The determination of probable cause will be based on a thorough assessment of the facts and circumstances of the incident and incorporates staff member's knowledge of the resident's usual and customary trends and patterns, physical abilities and limitations, medical conditions and medications, behavioral manifestations, etc. Although an incident was not witnessed, the assessed factors lead the staff to determine with considerable certainty the probable cause of the incident and any resulting injury. When cause or probable cause is determined, the resident care plan will be revised to ensure a corrective plan is in place to prevent recurrence. c. The supervisor will ensure that the resident(s) is/are protected from harm during the investigations. d. An incident report and investigation must be completed for any violations of this policy using the facility incident report in ECS or narrative statements. e. The residents' attending physician, facility medical director, corporate management and family will be notified as soon as possible. f. An employee suspected of violations of these Resident Safety Policies may be suspended during investigation. g. If a family member or other visitor is suspected of violation of these policies they may not be allowed to visit the resident or in any other way have access to the facility pending investigation. h. All witnesses or involved parties will be interviewed giving their own description of the incident. These records will become part of the permanent investigation file. i. The Quality Assurance Manager and/or supervisor on duty will interview the resident as well as any nursing, housekeeping, laundry, dietary, activity, or social service staff, any visitors or others who may have knowledge of the occurrence or who may have been in the vicinity at the time the incident happened. j. The Quality Assurance Manager and/or supervisor on duty will prepare written summary of each interview. k. The Administrator will designate appropriate personnel to handle any calls or questions about the incident. The Administrator will coordinate release of information to the media. The investigation will be conducted following the suggested procedures and measures in the facility reporting guidelines. l. A family member of other visitor found to be in violation of the resident safety policies will be reported to the local law enforcement and others as appropriate. m. The Administrator will be the custodian of all documents generated during the course of the investigation. n. These documents will be identified as Quality Assurance documents and will be reviewed by the Quality Assurance Committee for re-evaluation of the policies and procedures and for revision to the same policies and procedures if warranted to prevent further occurrences. Resident Rights: 28. The Resident has the right to be free from verbal, sexual, physical, or mental abuse... Review of Personnel Records: 1. Review of personnel records for staff members G, H, I, J, K and L showed lack of licensure for one staff member, (G), lack of background checks for five (H, I, J, K and L), and a lack of counseling for one(H)staff member. a. Review of the personnel file for staff member G, LPN, reflected she was was hired by the facility on 2/4/14 with a background check completed on 2/11/14. The personnel record lacked a current nursing license. During an interview on 10/27/14 at 5:00 p.m. staff member B, DON, was asked to provide a current Licensed Practical Nurse license for staff member G. Staff member B stated staff member G told her she had applied for a Montana license and sent them (Board of Nursing) a check, so she thought she had a license. The facility and surveyors looked online at Montana State Licensee Lookup and found a license for staff member G that was terminated in 2001 from Georgia. Staff member B was notified of the lack of licensure for staff member G and was asked to remove her from her nursing duties. Staff member B immediately spoke with staff member G and informed her she could not work as a nurse without a nursing license. During an observation on 10/28/14 at 5:15 p.m., staff member G was at the medication cart, unsupervised. The DON was notified that staff member G had been in the medication cart. Staff member B, DON, stated "Well, they have to count narcotics before she can leave." Staff member B was again informed that staff member G did not have a license and was not able to practice nursing. Staff member B again asked staff member G to leave the building. Staff member G left the building at 5:30 p.m. b. Staff member H, CNA, had a hire date of 5/20/14 with a background check completed on 7/8/14. c. Staff member I, RN, had a hire date of 5/27/14 with a background check completed on 7/8/14. d. Staff member J, RN, had a hire date of 2/15/13 with a background check completed on 3/20/13. e. Staff member L, CNA, had a hire date of 7/22/14 with a background check completed on 8/14/14. Staff member L did not have a date or supervisor signature on the General Orientation Outline which reviewed abuse in her personnel file. In an interview on 10/28/14 at 3:04 p.m., staff member R, accounts payable, stated background checks are usually done within one week of hire and licenses and certifications are looked up online prior to working. The facility allowed staff members G, H, I, J, K and L to work with residents without prior to completing background checks or verifying current licensure. Abuse Training: 2. During an interview on 10/27/14 at 4:40 p.m., staff member G, LPN, was asked to identify the different types of abuse she had been trained on at the facility. Staff member G replied, "elderly, children, bruising, hand prints." Staff member G was asked two more times if she could identify the different types of abuse. She stated she had been trained on abuse at previous jobs and knew what abuse was. Staff member G was not able to define abuse and stated she had not had any abuse training at the facility. During an interview on 10/28/14 at 2:05 p.m. staff member C, Social Services, stated that during new employee orientation, each department does an overview and Social Services goes over Resident Rights and Abuse. She further stated that she does annual abuse training for the employees which is mandatory and the employees have a choice of two days to attend. Review of an Employee Inservice Attendance Record dated 8/4/13 at 1:45 p.m. reflected staff members, A, B, and C presented an inservice on abuse and neglect, communication to residents and families and care plan process. Seventeen CNA's and seven licensed nurses attended the inservice. Two CNA's were from the night shift and staff member G, LPN did not attend. Review of an Employee Inservice Attendance Record dated 9/23 and 9/24/14 at 1:45 p.m., reflected staff member C presented an inservice on rights, abuse, reporting suspected allegations, phone privacy and more topics. Staff member C stated this training was to include all staff. Twenty CNA staff attended, one was from the night shift. Four licensed nurses attended for a total of 24 out of 46 direct patient care staff. Nine non nursing staff attended. During an interview on 10/28/14 at 3:00 p.m., staff member C stated she held the inservice for two days and the staff needed to attend one of the sessions. Sufficient Staff: 3. During an interview on 10/28/14 at 10:50 a.m. staff member B, DON, stated the staffing for CNA's is between six and eight for day shift, six and seven for afternoons, and nights would be three to four. For licensed nursing staff, they would have three on days and afternoons, unless the census is low, then there would be 2 1/2 and one nurse on the night shift. She also said if there is not enough staff that the facility would first see if anyone would volunteer to work and if not then the staff would be mandated to stay over from the shift they just worked. During an interview on 10/29/14 at 3:00 p.m., staff member A, Administrator, stated if the resident is at the end of a hall they will not have constant observation, regardless of the number of staff. In an interview on 10/29/14 during an afternoon meeting, staff member C, Social Services stated there is not enough staff. During an interview on 10/28/14 at 8:50 a.m., staff member M, LPN, stated they are short staffed and they are mandated to work extra shifts. Sometimes the staff will call off ten minutes before their shift or not show up at all. Timely Reporting and thorough Investigation of Incidents: 4. Review of The Reportable Incidents sent to the State Agency showed: a. The date of an alleged incident on 2/27/14 was reported to the State Agency on 3/4/14. b. The date of an alleged incident on 4/25/14 was reported to the State Agency on 4/29/14. c. The date of an alleged incident on 7/14/14 was reported to the State Agency on 7/17/14. The facility failed to complete a thorough 5 day investigation of the incident. Review of an incident dated 7/24/14 showed the facility documented counseling for staff member H, CNA in regards to the appropriate way to check for incontinence and how to talk to the resident during cares. Staff member H's personnel file was reviewed and the documentation for the above mentioned counseling was not found. During an interview on 10/28/14 at 3:30 p.m., staff member B, DON, stated, "If the employee is counseled by me the documentation would be found in the employee personnel file. I would make the decision whether to counsel the employee or not." d. The date of alleged incident on 8/1/14 was reported to the State Agency on 8/5/14. e. The date of alleged incident on 8/23/14 was reported to the State Agency on 8/26/14. The facility failed to complete a thorough 5 day investigation of the incident. f. The date of an alleged incident on 9/20/14 was reported to the State Agency on 9/24/14. Review of the incident 5 day investigation stated staff member G would be evaluated week to week for the next 60 days by the DON, as to how she is dealing with the residents on the new wing. This includes visiting with those residents of the area she is working in. During an interview on 10/28/14 at 3:30 p.m. staff member B, DON, stated she did not have written documentation of the weekly evaluations for staff member G, or interviews of the residents. Staff member B stated she just visually observed her and she was doing fine. Staff member B stated, "if the employee is counseled by me the documentation would be found in the employee personnel file. I would make the decision whether to counsel the employee or not. If I do not have a concern with a staff member during an investigation I do not document anything." During an interview on 10/28/14 at 2:05 p.m., staff member C, stated that after an investigation is completed, the Administrator, DON, and Social Services get together so they can be notified of the outcome of the investigation. If it is a staff to resident incident, Social Services and the DON would get together after the investigation has been completed. Staff member C stated, "staff member B has the final say over staff." 5. Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. During an interview on 10/30/14 at 3:10 p.m., the resident said the facility did not have "...enough aides and she frequently had to wait an extra long time to get help." On one occasion she said she "was left on the toilet for 45 minutes" which she reported to the Administrator and director of nursing. A male caregiver at night was verbally "sarcastic." He would never explain what care he was going to provide. The resident requested this staff member not provide care for her and requested female caregivers for her personal hygiene needs at night. After this, a female staff member would occasionally assist her, but would not always come to her room when the light was on, or she would make the resident wait for long periods before providing assistance. The resident said most nights the male caregiver, whom was involved in an abuse allegation toward the resident previously, was providing her care. Review of an incident report dated 7/24/14 showed an allegation that named the above staff member read: "Nursing reported that the resident was told to 'wet' in her brief." Review of a nursing progress note dated 10/17/14 at 3:35 a.m., showed that the nurse on duty documented, "pt informed that there were only male CNAs on NOC. Pt informed that the only female on shift is the nurse, and the nurse is caring for all residents and may not have time to provide care. Pt asked who CNAs were. Informed that they were (name) and (name). Pt states that she wanted (name) to care for her. Pt informed that (name) is on the opposite wing and has to provide care for his pt's, and if he has time, he will answer her call. Pt stated that she may just urinate in her brief. Pt informed that this is her right to make that decision if she so chooses. Pt is currently resting ... " Review of the resident's care plan and CNA Assignment Sheet failed to include the resident's request for female caregivers at night. The social service progress notes lacked evidence of any concerns relating to female caregivers, or concerns relating to the resident's stay. During an interview on 10/30/14 at 1:10 p.m., staff member B, Director of Nursing, discussed what action would be taken if a resident requested female caregivers. Staff member B said, "At night with males, the nurse is female, so she would go with men for care, or do the care herself." During an interview on 10/30/14 at 5:15 p.m., staff member A, Administrator, said he was aware of the resident's concerns with male caregivers on the night shift. He said if a female nurse was working, she would be expected to help the resident in place of the male staff if needed.

Based on observations, interviews and record reviews, the facility failed to provide the necessary care to maintain the highest practicable well being for 3 (#s 9, 10, and 11) of 16 sampled residents. Specifically, the facility failed to notify the physician of wounds, failed to obtain orders for wound care, failed to follow the physician's orders [REDACTED]. An Immediate Jeopardy was called on 10/29/14 at 1:30 p.m. Specific Failures were: 1. The facility failed to notify physicians of resident wounds; 2. The facility failed to obtain orders for wound care and failed to follow the physician's orders [REDACTED]. 3. The facility failed to use aseptic technique during wound care. Plan to Abate Immediate Jeopardy: All nursing staff shall be educated by Real Property Health (RPH) staff, beginning immediately, on the identification and treatment of [REDACTED]. A copy of training material will be provided to the department. The RPH policy is reviewed in Executive QAPI and the content is consistent with current standards of practice. All nursing staff shall be immediately counseled for failure to follow MD orders, as appropriate. Nurse training shall be provided by and at the direction of Real Property Health corporate staff beginning 10/30/14 at 1:30 p.m. by a corporate RN, BSN, WCC, RAC-CT. Training shall be provided remotely through the web and/or onsite by qualified staff. The content of the training shall be available for department review and shall include standards of practice in wound care, infection control, and physician orders. Staff performance shall be audited onsite no less than weekly for the next 6 weeks by corporate nursing staff and weekly via remote medical record review of MD orders, treatment records and nurses notes. Immediate short-term plans for onsite review include (name) VPO, NHA to be onsite the week of 11/3/14, and (name), BSHCA, NHA, RAC-CT and (name) BSN, NHA, RN, WCC, AC-CT to be onsite the following week. Beyond the initial 6 weeks, the company will plan onsite visits no less than biweekly for two months and monthly thereafter or as needed. The schedule frequency may change with mutual agreement between the facility and the state agency. The correction plan was accepted and the immediate jeopardy was abated on 10/30/14 at 9:50 p.m. The deficient practice remained at the scope and severity of an H once the immediate jeopardy was abated. SPECIFIC FAILURES WERE: 1. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change MDS dated [DATE], reflected that the resident had a BIMs score of "3", indicating severely impaired cognition (C0500). Review of resident #11's hospital documentation from 8/26 - 8/29/14 reflected the resident was admitted to the hospital from her home with a primary [DIAGNOSES REDACTED]. Resident #11 had a medical consultation on 8/27/14, reflecting "dependent rubor and 1 to 2 plus [MEDICAL CONDITION] of both feet to knees. The left foot may be cooler than the right but it is not cold. There are multiple abrasions on both lower extremities, but no ulcers or necrosis." Review of the Nursing Progress Notes reflects: -8/29/14, "...patient has multiple wounds bilateral lower extremities...she is red in the groin area..." - 9/1/14, "...scarring on her left foot with some scabbing up on her legs... - 9/8/14, dressing change "...applied foam and [MEDICATION NAME]" Wound assessments reflected: 1) abrasions over front of calf, calf red, and open [MEDICAL CONDITION], L - 1.5 cm, W - 1.5 cm, and D - 0.3 cm. Has necrotic tissue without drainage and redness around the open [MEDICAL CONDITION]. 2) left foot ha open [MEDICAL CONDITION], L - 1.4 cm, W - 1 cm, and D - 0.2 cm. The tissue is necrotic with redness and [MEDICAL CONDITION] around the wounds. 3) open lesion on the foot, L - 1.8 cm, with necrotic tissue with redness and [MEDICAL CONDITION] around the wound. 9/10, dressing change "...changed L heel dressing..." Checked bilateral "scabbed scratches and remaining wounds, [MEDICAL CONDITION] on top of the feet..." Notification sent to the physician. On 9/11/14, a new wound care order was received. Duoderm was to be applied to the three [MEDICAL CONDITION] and changed every three days. Review of the September 2014 Treatment record reflects when the Duoderm was being changed and the corresponding nursing progress note: - 9/11, Dressing change -Duoderm (apply every three days) Checked bilateral "scabbed scratches and remaining wounds, [MEDICAL CONDITION] on top of the feet..." -9/12, "...legs appear red and cold to the touch..." -9/13, Dressing change - Duoderm (apply every three days). "...patient has some scabs that (are) red, no drainage...on left calf and left foot..." -9/14, Dressing change - Duoderm (apply every three days). "...patient has some scabs that (are) red, no drainage...on left calf and left foot..." -9/15, "...slight improvement..." -9/16, checked bilateral lower extremity "scabbed scratches and remaining wounds, [MEDICAL CONDITION] on top of feet..." On 9/16/14, the Meds All record reflects a new antibiotic order, [MEDICATION NAME] 500 mg by mouth daily X 10 days. - 9/17, checked bilateral lower extremity "scabbed scratches and remaining wounds, [MEDICAL CONDITION] on top of feet..." - 9/19, Dressing change - Duoderm (apply every three days). "...left foot with sores, foot purple/red in color..." - 9/20, checked bilateral lower extremity..."scabbed scratches and remaining wounds, 2 + [MEDICAL CONDITION] in legs...left foot is purple/reddish in color, wound is scabbed over but not healing, patient needs to see her doctor as soon as possible..." - 9/21, Dressing change - Duoderm (apply every three days) - 9/22, checked bilateral lower extremity..."scabbed scratches and remaining wounds, 2 + [MEDICAL CONDITION] in legs...continues to receive antibiotic...left foot is purple/reddish in color, wound is scabbed over...phoned MDs office and notified nurse...wounds do not appear to be healing...referred to Wound Rehab at (Hospital Name), appointment this (Wednesday)." - 9/24 (Wednesday), "...stabbing pain to left foot area. Left leg increasing in area of redness, 3 + to extremity. Outer side of left foot...has excoriated area - quarter sized." Notification sent to the physician. On 9/24/14, resident # 11 was seen at (name of facility) Wound Care Clinic. Review of physician progress notes [REDACTED]. Please change BID or PRN when saturated. Secure with soft gauze & use medigrip for some compression over all. Will like to see 2 X week for sharp debridement. Please call to schedule." During an interview on 10/27/14 at 4:45 p.m., staff member W, RN, stated she found resident #11's Wound Care Clinic orders mis-filed and the order was never started. She stated this error was found about one and one-half weeks ago and was reported to the director of nurses. Review of the Treatment record reflects: 9/25, Dressing change - Duoderm (apply every three days). 9/26, checked bilateral lower extremity "scabbed scratches and remaining wounds, 2 + [MEDICAL CONDITION] in legs...malaise today, emesis X 1..." 9/30/14, Dressing change - Duoderm (apply every three days). "...Patient's left foot is swollen 2 +, left foot is purple/reddish in color, wound is scabbed over but not healing, patient needs to see her doctor as soon as possible...pain in left foot..." 10/1, "...mental status change...lungs very congested...notified Dr..." and suggested an ER evaluation. The record from 8/29 - 10/1/14 shows that the resident's left foot developed three open wounds and this was identified ten days after the admission to the facility. Open [MEDICAL CONDITION] to the left foot were identified on 9/8/14, and orders were obtained on 9/11/14. The 9/11/14 Duoderm dressings were not being changed every three days as ordered. The 9/24/14 orders from the Wound Care Clinic were not followed. Additionally the resident was not seen twice weekly at the Wound Care Clinic for debridement as ordered. [MEDICATION NAME] was started on 9/16/14 and continued ten days, but the status of resident's left leg wounds continued to worsen until resident was hosptalized on [DATE]. Resident #11 was hospitalized from 10/1 - 10/7/14. The record reflected her primary [DIAGNOSES REDACTED]. Additional related [DIAGNOSES REDACTED]. The medical consultations on 10/4/14 reflected "...life threatening gangrene of left foot...must undergo amputation of her left foot if she is to recover...amputation tomorrow..." The resident did not undergo an amputation due to a medical complication. The discharge summary reflected "consider transition to palliative care and comfort care..." Review of the Treatment record reflects: 10/7, readmitted to the facility. "[MEDICAL CONDITION] in (lower extremity)...coccyx red and per-area red...multiple wounds on (lower extremity)...left leg is the worse for her wounds...most of her wounds are scabbed over, ...right leg has scratches from her cat..." 10/12, Dressing change - "...applied a non-adherent sterile pad...wrapped the foot in Kerlix..." the old soiled dressing which was removed was "...saturated through the Polymem with dark gooey drainage. There are three wounds that appear to have grown together into one large wound, A large amount of the skin in the wound was [MEDICAL CONDITION] 3 + lower extremity..." 10/13, "...wounds are the same, seem to not (be) healing, just staying the same..." Review of the Nursing Progress Notes dated from 10/14/14 through 10/18/14 did not reflect an assessment of the resident's BLEs. 10/19, open lesion on top of foot, wound bed red, yellow, odorous, light exudate. The surrounding tissue is mushy, red with [MEDICAL CONDITION]. The record lacks a wound measurement. On Sunday, 10/19/14, the facility sent a facsimile communication to the physician which reflected, "Pt has statis (sic) ulcers on outside of left foot, Wounds are deteriorating, Would like to use Calcium Alginate and [MEDICATION NAME]. Please advise. The physician documented on the facsimile under physician orders, "Calcium Alginate," signed the order, and dated it 10/20/14. The facility RN noted the order and signed and dated it on 10/22/14. Review of the Treatment record reflects that calcium alginate was ordered 10/22/14 and was to be applied to the outside of the left foot and changed daily. Review of the signature block of the treatment record reflected the treatment was not begun until 10/24/14. Review of the Nursing Progress Notes reflected: 10/23, "...multiple wounds that are open and infected...slough, necrotic ...greenish-yellow" tissue. The area surrounding the wound is red, warm and [MEDICAL CONDITION]. The wound is worsening and becoming larger and deeper with tenderness present. 10/24, "...purple/maroon colored, surrounding tissue cooler than adjacent tissue, surrounding tissue mushy/boggy.... slough...necrotic, greenish-yellow tissue...cyanosis noted...moderate exudate...odorous...worsening..." 10/25/14 ...lower extremities have 3+ [MEDICAL CONDITION], wounds have continuously declined, wounds have an odor to them. Wounds are covered with a gray whitish slough. 10/26, "...last day of antibiotic...Purple/maroon colored, surrounding tissue painful, surrounding tissue mushy/boggy,...Appearance of blood-filled blister, surrounding tissue cooler than adjacent...moderate exudate...no odor present...worsening. 10/27 no documentation/assessment of the resident's BLEs reflected. 10/28/14 ...no change in foot condition as of 10/27/2014. On 10/28/14, resident # 11 was seen at (Hospital name) Wound Care Clinic. Review of physician progress notes [REDACTED]. (Name) to make orthopedic referral. No further appointments planned at this time. Resident #11's facility record from 10/7 - 10/28/14 lacks evidence of wound care orders from 10/7 - 10/22/14, and evidence that wound care was provided more than once between 10/7 - 10/22/14. Resident had an unnecessary delay in treatment between 10/19/14 and 10/22/14. On 10/28/14 at 10:25 a.m., staff member X, CNA, provided peri-care and the resident #11's skin was observed. The resident was lying in bed and had her left foot partially dressed in a gauze roll. Her left toes were purple, and a large fluid filled blister was partially exposed beyond the dressing on the anterior surface of the foot adjacent to her toes. The blister was approximately four centimeters in width. The sacral area was observed. The area above the gluteal crease was red with rough texture indicative of shallow scattered skin loss or abrasions, approximate length six centimeters by width of four centimeters. Staff member X applied pressure to the red area, and it did not blanch. Also upon observation, the right ischial tuberosity area was red, immediately below the gluteus and at the juncture of her upper thigh. The approximate length was four centimeters by width of three centimeters. On 10/28/14 at 10:35 a.m., staff member J, RN, provided wound care and resident #11's left foot was observed. Resident's toes were purple, and the skin was red. Four wounds were observed: 1) one large black eschar covering the heel, and 2) one on the mid-sole of her foot, 3) a large red open area on the anterior surface and proximal to the ankle, 4) and a large fluid filled blister on the anterior surface proximal to her toes. During an interview on 10/28/14 at 10:35 a.m., staff member J, RN, stated resident #11's wounds keep getting worse and the RN was not sure why; she thought it might be related to the resident's uncontrolled [MEDICAL CONDITION]. She said wound care was not ordered on readmission of 10/7/14. On 10/28/14 at 10:35 a.m., staff member J, RN, provided wound care for resident #11's left foot. Observations of the wound care included breaches in aseptic technique and in appropriate hand hygiene. - Staff member J removed the soiled dressing and placed the resident's left foot with open wounds directly on the bed covers. - Staff member T, CNA held her soiled (from assisting the resident with dressing and opening window blinds) glove against the dressings, while staff member J wrapped the foot in a gauze roll. - Staff J did not change her gloves and complete hand hygiene between removing the soiled dressing and applying the clean dressing. - Calcium alginate was placed on the open wounds and covered with a self adhesive [MEDICATION NAME] Pad. The adhesive edge was placed directly over several of her open wounds. Resident #11's care plan for 10/7/14 was reviewed. It reflected: "Impairment of skin integrity" and included nursing interventions: "...assess skin condition daily, and measure area..." Review of the Nursing Progress Notes reflects resident #11's open wounds were identified on 9/8/14. The record lacks evidence that daily skin assessments were completed. Wound measurements present on 9/8/14; review of the record lacked subsequent wound measurements. During an interview on 10/30/14 at 3:10 p.m., staff member E, LPN, stated resident #11's care plan was appropriate but generic: for example, "treatment as ordered". In an interview on 10/30/14 at 5:05 p.m., staff member W, RN, stated that resident #11 had a stage II pressure sore on buttocks and that she was aware of the condition because of recent word of mouth by the other nurses. She looked at the current Treatment Record, and stated there were no current treatments ordered for the pressure sore. The MDS dated [DATE], reflected that resident #11 had one or more unhealed pressure sores (M0210) and three unstageable pressure sores due to eschar or slough, and these were present on admission (M0300F). The hospital records from 8/29/14 - 8/29/14 were reviewed. The Discharge Summary did not reflect pressure sores as a [DIAGNOSES REDACTED]. The left foot may be cooler than the right but it is not cold. There are multiple abrasions on both lower extremities but no ulcers or necrosis." The significant change MDS dated [DATE] reflected that resident #11 had one or more unhealed pressure sores (M0210), had one stage II pressure sore and there were present on admission or readmission (M0300B). The hospital records from 10/1 - 10/7/14 were reviewed. The Discharge Summary did not reflect pressure sores as a [DIAGNOSES REDACTED]. Review of the Nursing Progress Notes reflected: 10/7, "...coccyx red..." No evidence of measurement taken or further description. In an interview on 10/30/14 at 5:45 p.m., staff member W, RN, stated the facility has many documentation processes, but it is very difficult to see each specific wound's progress unless the same nurse is routinely completing the wound care. Additionally, she said nurses document on some wounds and not on others, or they will not name the sites (anatomical) the same. 2. Resident #9 was originally admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The resident's admission MDS dated [DATE] reflected a BIMS score of "15" indicating the resident was cognitively intact. (BIMS - C500). Review of resident #9's hospital documentation from 8/18 - 8/27/14 reflected the resident complained of a sore buttocks on admission, but the attending was not able to identify anything obvious. The resident's primary hospital [DIAGNOSES REDACTED]. In an interview on 10/27/14 at 2:40 p.m., resident #9 stated she currently had wounds on her posterior upper thighs and buttocks caused by pressure when sitting in her chair. Review of the Nursing Progress Notes reflected wound status assessments: - 8/1 - 8/18/14, the nursing progress notes made no reference to skin status or assessments. -8/18, had an acute change of status and was admitted to the hospital from 8/18 - 8/27/14 for [MEDICAL CONDITION] to her left lower extremity. In an interview on 10/30/14 at 5:05 p.m., staff member W, RN, stated when resident #9 returned from the hospital and was readmitted to the facility on [DATE], the wounds on her buttocks and posterior thighs were almost healed. Continued Nursing Progress Notes: --8/27, "...pt has [MEDICAL CONDITION] on left leg. On right leg she has small open area. Pt has a small open area on left side of buttocks. She has bruises on her buttocks." -8/28/14, "...left posterior calf has peeling that looks to be from dryness..." -8/30/14, "...redness seems to be improving..." -9/2/14, "...Skin is intact..." -9/4/14, foley urinary catheter removed. -9/8/14, "...no sign or symptoms that [MEDICAL CONDITION] is returning..." -9/9/14, "...bed pan discontinued..." -9/12/14, "...left lower leg and calf area larger red area (,) noted heat from site, no smell but resident states it is painful...buttocks remains the same...Left leg is swollen and red and warm to the touch. lower part of (left) ankle was red blotches around her leg and was warm to the touch..." Antibiotics started, two punch biopsy to left leg obtained. -9/15 at 3:31 p.m., "[MEDICAL CONDITION] outline still on leg and the area has decreased. The area that Dr. (name) punctured is more reddened..." -9/15 at 8:58 p.m., "...pt left ankle is dry and flaky. Only red area is on her left knee where she had needle biopsy..." -9/17, "...puncture biopsy site looks to be healing..." -9/21 at 2:21 p.m., "...some of the stitches on left knee has dissolved..." -9/21 at 10:11p.m., "...Area on bottom of buttocks appears to be increasing. [MEDICAL CONDITION] area is decreasing, redness remains the same..." -9/22 at 2:58p.m., "...Left leg [MEDICAL CONDITION] remains the same. Area on buttocks continues to break down..." -9/22 at 8:27 p.m., "...area where biopsy was continues to be red, no discharge noted..." -9/23 at 2:52 a.m., "...redness reduced on both legs..." -9/23 at 9:17 p.m., "...Left leg [MEDICAL CONDITION] appears to be reducing in size..." -10/3, "[MEDICAL CONDITION] is healing with redness and warmth and swelling decreasing..." -10/6 at 2:59 a.m., "...redness seems to be decreasing..." -10/6 at 7:07 p.m., "[MEDICAL CONDITION] is healing..." -10/7, "...decreasing redness. Puncture sites are healing..." -10/8 at 1:13 a.m., "...decrease in redness, puncture sites fress of an s/s of infection..." -10/8 at 1:08 p.m., "...Buttocks is starting to [MEDICAL CONDITION] is still continuing to heal..." -10/9, "...lower extremities, redness/irritation reduced. Puncture sites free of any s/s of infection..." -10/11, "...biopsy (sites) are red..." -10/12, "[MEDICAL CONDITION] in left leg decreased and and is no longer warm..." -10/13, "...lower legs, redness greatly reduced. Puncture sites reduced in size..." -10/17, "...lower extremities, redness greatly reduced...posterior upper thighs, skin breakdown still present..." -10/21, "...blister type sore...right anterior lower leg, tissue pink, light exudates...resident states this "blister" type sore is what she had previously that progressed into tunneling." -10/22 - 10/28/14, the nursing progress notes made no reference to skin status or assessments. Resident #9's facility record from 8/29 - 10/28/14 reflects that most skin creases are red. Additionally resident has non-blanching bilateral red rough areas over her ischial tuberosities. In an interview on 10/27/14 at 3:25 p.m., staff member U, CNA, stated resident #9 had open sores and redness behind her legs, under her breasts, and groin. She said the worst areas were like little sores that were about to open up. Resident #9's skin status was observed on 10/28/14 at 11:15 a.m., during wound care completed by staff member M, LPN: - Under bilateral breast creases, redness present with an approximate length of eight centimeters by width of 0.3 centimeters. Laterally under the left breast the redness was the diameter of a large grapefruit. - Under the abdominal fold was a scattered, intermittent redness. Under the left side of the abdominal fold was a solid red area approximately the diameter of a large plum. -From the abdominal area to the pubis was a scattered slightly raised red rash, without pustules, drainage or scabs. - The bilateral upper inner thighs adjacent to the pubis had scattered reddened areas deep into the fold creases. - The four bilateral deep anterior thigh creases had scattered minor red areas. - The two bilateral wounds in the lower gluteal area were superior to the ischial tuberosity areas. These wounds mirrored each other bilaterally and were uniformly bright red and had a rough texture indicative of shallow scattered skin loss or abrasions. Staff member M, LPN checked for blanching with pressure, no blanching occurred. Each wound was an approximate size of four centimeters by six centimeters. -The two bilateral wounds present in the upper posterior aspect of the thighs and adjacent to the gluteus were superior to the ischial tuberosities. These wounds mirrored each other bilaterally and were bright red, and had a rough texture indicative of shallow scattered skin loss or abrasions. Staff member M, LPN checked for blanching with pressure, no blanching occurred. Each wound had an approximate length of seven centimeters by a width of five centimeters. -The two bilateral wounds between the lateral and distal aspect of the gluteus and the lateral proximal aspect of the upper thighs, and deep in the creases had dark red areas. Each wound had an approximate length of three centimeters by 0.5 cm in width. The right side additionally had a small open area approximately 0.5 cm in diameter. -The four bilateral deep posterior calf folds, were intermittently red, approximate length five centimeters by 0.5 centimeters width. - The two right mid-anterior shin red blisters, were each approximately 0.5 centimeters in diameter. In an interview on 10/30/14 at 3:10 p.m., staff member E, LPN/MDS Coordinator, stated there was a nursing meeting today and the nurses were concerned about resident #9's skin, and stated the nurses said "it's a mess!" Review of the admission MDS dated [DATE] for bed mobility (G0110A) reflected the resident's bed performance required extensive assistance (3), but the actual support provided by staff was limited (2). Review of the nurse's note dated 9/5/14 reflected, "...requires no help from staff for bed mobility..." In an interview on 10/27/14 at 2:40 p.m., resident #9, stated she could change her own position independently. In an interview on 10/27/14 at 3:25 p.m., staff member U, CNA, stated resident #9 could reposition her self in the recliner. The CNA said the resident was helped to reposition every two hours, but the resident refuses to lie on side while in bed. Additionally, staff member U stated that the resident spends most of the day in bed. In an interview on 10/30/14 at 1:15 p.m., resident #9 said the CNAs do not routinely help the resident change position and resident assumed that staff thinks resident will change own position. Resident stated that she can reposition self in bed, but it is much harder to change position in the recliner chair. In an interview on 10/30/14 at 5:50 p.m., staff member V, CNA, stated she routinely assisted resident #9 with lotion on her legs, creams on buttocks, personal hygiene, set up for meals, bathing and transferring. The stated care duties were repeated and asked if there were any other important care duties, she said "no". Staff member V did not list assisting resident #9 with changing position every two hours. During an observation on 10/28/14 at 11:15 a.m. staff member M, LPN, completed wound care for resident #9. - Staff member M's hair was approximately five inches below her shoulders and it was not restrained. The nurse was leaned over the resident providing wound care. Staff member M wore five finger rings. - On two occasions, Staff member M failed to complete hand hygiene after removing gloves during wound care. - Staff member M touched her gloved hand to her face and to her hair once, and proceeded with wound care without removing her gloves and completing hand hygiene. - Staff member M left the resident's room, opening the door with the soiled glove. - Staff member M asked the resident, what type of treatment was being applied for different wounds: What are they using for your your peri-area...Are we dressing this one?...Are we still doing wet to dry dressings? -[MEDICATION NAME] ointment was used on the left upper thigh instead of [MEDICATION NAME] spray and Elton cream that was ordered. -A daily wet to dry compression was ordered to right lower leg, but a foam dressing was placed over the wound, then covered by non-adhesive pad, and secured with tape. On 10/28/14 at 11:15 a.m., Resident #9 said the staff had not completed any cream application to her buttocks yesterday and the facility did not have any Elta cream. In an interview on 10/30/14 at 5:05 p.m., staff member W, RN, reviewed resident #9's electronic treatment record. She said the record is confusing: 1) The [MEDICATION NAME] spray and Elton cream was ordered for left upper thigh twice a day, but the resident has similar wounds on both thighs. The order for the thigh wound did not have a diagnosis. 2) The order for barrier cream/[MEDICATION NAME] to buttocks, was probably a duplication of the order to apply thick [MEDICATION NAME] to the skin superior to anal verse (sic). The buttocks orders did not have a definitive geographic location or diagnosis. 3) The order to apply daily wet to dry compression to right lower leg, does not narrow the geographic area of the wound, and it lacks a diagnosis. Review of the current physician orders [REDACTED].#9 may not have the bedpan, (but should) use the bedside commode. The review of the resident's medical on 9/9/14 reflected, "Orders for D/C bedpan completely and use bedside commode due to skin breakdown, needs to be watched closely and taken off commode as soon as she is done." In an interview on 10/27/14 at 3:25 p.m., staff member U, CNA, stated resident #9 could roll side to side to used the bed pan. CNA said it was the resident's decision to choose the bedpan or the bedside commode. In an interview on 10/30/14 at 1:15 p.m., resident #9 said during the night and when in bed, the resident prefers to use the bed pan. The 2014 August Treatment record reflected the following orders: - [MEDICATION NAME] powder to apply topically three times daily, for a skin yeast infection, started 3/14. - Apply [MEDICATION NAME] spray and elta cream to left upper thigh twice aday, started 4/14. - Ammonium [MEDICATION NAME] 12% lotion topically daily for excessively dry skin, started 8/27/14. The 2014 August Nursing Progress Notes and Treatment record lacked evidence of topical treatment applications on the following days: - [MEDICATION NAME], mornings of August 12, 28, 29 / midday of August 1, 5, 6, 12, 13, 16, 28, 30 and evenings of August 7. - [MEDICATION NAME] spray and elta, mornings of August 3, 4, 12 and evenings of August 7. The 2014 September Treatment record reflected the following orders: - Apply [MEDICATION NAME] spray and elta cream to left upper thigh twice a day, started 4/12/14. - Apply [MEDICATION NAME] spray and elta cream to left upper thigh twice a day, started 4/14. - Apply thick barrier cream [MEDICATION NAME] to buttocks wounds three times daily and as needed, started 9/15/14. - To skin superior to anal verse (sic) apply thick [MEDICATION NAME] to midline. Apply [MEDICATION NAME] powder to skin surrounding gluteal midline three times daily and as needed, started 9/15/14. - Assess left leg for homeostasis at puncture site and outline [MEDICAL CONDITION] (each shift), started 9/15/14. - Ammonium [MEDICATION NAME] 12% lotion topically daily for excessively dry skin, started 8/27/14. - The weekly skin assessments on bath day, started 2/13/14. The 2014 September Nursing Progress Notes and Treatment record show no evidence of topical treatment applications on the following dates: - [MEDICATION NAME], mornings of September 1, 4, 6, 7, 13, midday of September 1, 3 - 7, 10, 11, 13, 14, and evenings of September 13, 14. - [MEDICATION NAME] spray and elta cream, mornings of September 1, 4, 6, 13, 25 - 29, evenings of September 5- 29. - [MEDICATION NAME] to buttocks wounds, mornings of September 16, 25-29, middays and evenings of September 25 - 28. - [MEDICATION NAME] to anal verse (sic), mornings of September 25 - 29, middays of September 20, 25, 26, 28, and evening of September 27. - Assess left leg for homeostasis mornings of September 16,19, 22, 25-27, 29 and middays of September 25 - 27. - Ammonium [MEDICATION NAME] 12% lotion September 1, 4, 6, 7, 13, 16, 26 - 29. - Weekly skin assessments September 7. The 2014 October Treatment record reflected the following orders: - Apply [MEDICATION NAME] spray and elta cream to left upper thigh twice a day, started 4/14. - Apply thick barrier cream [MEDICATION NAME] to buttocks wounds three times daily and as needed, started 9/15/14. - To skin superior to anal verse (sic) apply thick [MEDICATION NAME] to midline. Apply [MEDICATION NAME] powder to skin surrounding gluteal midline three times daily as needed, started 9/15/14. - Ammonium [MEDICATION NAME] 12% lotion topically daily for excessively dry skin, started 8/27/14. -Apply daily wet to dry compression to right lower leg, started 10/23/14. The 2014 October electronic Nursing Progress Notes and Treatment record show no evidence of topical treatment applications on the following dates: - [MEDICATION NAME] spray and elta cream, mornings of October 1, 3, 7, 11, 13, 15, 18, 20, 22, 25, 27, and evenings of October 2, 8, 12, 26, 27, 28. - [MEDICATION NAME] to buttocks, mornings of

Based on record review and interview, the facility failed to ensure the services being provided were provided by licensed nursing personal and met professional assessment standards. Specifically, the facility failed to ensure 1 (#11) of 16 residents received appropriate, timely assessments, treatments, wound care, and the the physician was notified of acute changes in the resident's condition. The facility further failed to ensure nurses followed physician orders [REDACTED]. The facility failed to ensure nurses did not delegate topical medication applications to unqualified staff, failed to ensure staff clarified wound care orders and failed to ensure staff notified the physician for wound care orders for a skin tear for 3 (#s 8, 9 and 10) of 16 sampled residents. An Immediate Jeopardy was called on 10/29/14 at 1:30 p.m. PLAN TO ABATE IMMEDIATE JEOPARDY AS SUBMITTED BY FACILITY: All staff shall be immediately trained by corporate nursing staff on the identification and treatment of [REDACTED]. A copy of training materials will be provided to the department. (State Agency). The Real Property Health (RPH) policy is reviewed in Executive QAPI and the content is consistent with current standards of practice. The correction plan was accepted and the immediate jeopardy was abated on 10/30/14 at 9:50 p.m. Once the immediate jeopardy was abated, the deficient practice was lowered to the severity and scope of H . FINDINGS INCLUDE: 1. Review of personnel records for staff member G showed lack of nursing licensure: a. Review of the personnel file for staff member G, LPN, reflected she was was hired by the facility on 2/4/14 with a background check completed on 2/11/14. The personnel record lacked a current nursing license. During an interview on 10/27/14 at 5:00 p.m., staff member B, DON, was asked to provide a current Licensed Practical Nurse license for staff member G. Staff member B stated staff member G told her she had applied for a Montana license and sent them (Board of Nursing) a check, so she thought she had a license. The facility staff and surveyors looked online at Montana State Licensee Lookup and found a license for staff member G that was terminated in 2001 from Georgia. Staff member B, was notified of the lack of licensure for staff member G and was asked to remove her from her nursing duties . Staff member B immediately spoke with staff member G and informed her she could not work as a nurse without a nursing license. During an observation on 10/28/14 at 5:15 p.m., staff member G was at the medication cart unsupervised. The DON was notified that staff member G had been in the medication cart. Staff member B, DON, stated "Well, they have to count narcotics before she can leave." Staff member B was again informed that staff member G did not have a license and was not able to practice nursing. Staff member B again asked staff member G to leave the building. Staff member G left the building at 5:30 p.m. 1. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change MDS, dated [DATE], reflected the resident had a score of "3" on C0500, showing severely impaired cognition. a. Review of the Nursing Progress Notes reflected: 8/29/14 9:43 p.m. "New Admission: admitted from: Acute Care Hospital......Pt has multiple wounds on bilateral lower extremities...She has 3+ [MEDICAL CONDITION] bilateral lower extremities. She is a brittle diabetic that is poorly controlled......Will continue to monitor resident." 8/30/14 8:07 p.m. Note: Resident is confused....2-3 + [MEDICAL CONDITION] in lower extremity...will continue to monitor. Review of the Nursing Progress Notes dated 8/31/14 did not reflect an assessment of the resident's BLE's. 9/1/14 9:58 p.m. "1+ [MEDICAL CONDITION] in her left and right feet." 10:00 p.m.: the patient has some scarring on her left foot with some scabbing up on her legs, the patient states that it's due to [MEDICAL CONDITION]." Review of the Nursing Progress Notes dated from 9/2/14 through 9/7/14 did not show documentation/assessment of the resident's BLE's. However, as the following note demonstrates, the resident had an open lesion present for the past seven days over the "front of her calf." 9/8/14 9:55 p.m."R lower calf reddened, abrasions over front of calf. Has open lesion(s) present in past 7 days. Length: 1.5 Width: 1.5 Depth: 0.3 cm....Necrotic tissue. No drainage. [DIAGNOSES REDACTED] present. Receives application of dressings...9:58 p.m. L foot reddened. Has open lesion(s) present in past 7 days. Has open [MEDICAL CONDITION] on the foot. Length: 1.4 cm Width: 1 cm Depth: 0.2 cm Necrotic tissue. Reddened. [DIAGNOSES REDACTED]. Receives application of dressings...foam and [MEDICATION NAME]. 10:00 p.m. "....Has open lesion(s) on the foot. Length: 1.8 cm diameter. Necrotic Tissue. Reddened. Pallor noted. [DIAGNOSES REDACTED] present..[MEDICAL CONDITION]. Receives application of dressings...foam and [MEDICATION NAME]. 9/9/14 9:09 p.m. "From the [MEDICAL CONDITION] the patient is having on her lower extremities, patient has some scabs that (sic) red, no drainage. Dr. ordered Duoderm for the scabbed red areas on patients (sic) left calf and left foot. .....Will continue to monitor." 9/10/14 11:28 a.m. Late entry for: 9/08/14 0600 -1400 (a.m. - 2 p.m.): "checked BLE scabbed scratches and remaining wounds, [MEDICAL CONDITION] in tips of feet, notified MD's office, awaiting return-call, notified on-coming nurse of situation.......03:15 p.m. (sic) checked BLE scabbed scratches and remaining wounds, [MEDICAL CONDITION] in tops of feet, legs are elevated; changed L heel dressing..." 9/11/14 03:02 p.m. (sic) Checked bilateral "scabbed scratches and remaining wounds, [MEDICAL CONDITION] on top of the feet..." 9/12/14 07:35 pm (sic) "...legs still appear red and cold to the touch..." 9/13/14 11:44 p.m. "...patient has some scabs that (are) red, no drainage...Dr. ordered Duoderm for the scabbed red areas on patients (sic) left calf and left foot..." 9/14/14 09:47 pm (sic) "...patient has some scabs that (are) red, no drainage...on left calf and left foot..." 9/15/14 05:22 (sic} Late entry for 9/12/14 "checked BLE scabbed scratches and remaining wounds. [MEDICAL CONDITION] in tops of feet." 9/16/14 12:54 p.m. Late Entry for 9/15 ...checked bilateral lower extremity "scabbed scratches and remaining wounds, [MEDICAL CONDITION] on top of feet..." 9/17/14, Late entry for 9/16/14 1:08 p.m. "checked bilateral lower extremity "scabbed scratches and remaining wounds, [MEDICAL CONDITION] on top of feet..." Review of the Nursing Progress Notes dated 9/18/14 did not reflect an assessment of the resident's BLE's. The physician was notified of the change in condition and that the resident lost sensation in left foot. Review of Nursing Progress Notes dated 9/24/14 at 5:04 p.m. reflected a late entry for 9/23/14 showing "2-3 + [MEDICAL CONDITION] in lower extremity and top of feet...will continue to monitor." This assessment lacked assessment of the loss of sensation or the change in color of the feet. 9/19/14 1:56 p.m. "...left foot with sores, foot purple/red in color..." 9/20/14 1:58 p.m. "Checked BLE scabbed scratches and remaining wounds. 2+ [MEDICAL CONDITION] in legs." 9/20/14 5:28 p.m. Late entry for 9/19/14 "...patient's left foot is swollen 2+. Left foot is purple/reddish in color; wound is scabbed over but not healing, patient needs to see her doctor as soon as possible for wound on that left foot..." 9/21/14 3:05 p.m. checked BLE scabbed scratches and remaining wounds, 2+ [MEDICAL CONDITION] in legs. 9/22 02:44 pm (sic) (Monday) checked bilateral lower extremity..."scabbed scratches and remaining wounds, 2 + [MEDICAL CONDITION] in legs...no sensation in L foot....continues to receive antibiotic...phoned MD's office and notified nurse of condition of BLE and sores do not appear to be healing...MD referred to Wound rehab at (local hospital) appointment set for this Wed." 9/24/14 4:03 a.m. (Wednesday), "...stabbing pain to left foot area. Left leg increasing in area of redness, 3 +[MEDICAL CONDITION] to extremity. Outer side of left foot...has excoriated area - quarter sized." "SBAR sent to the doctor. Will continue to monitor." Review of the resident's physician progress notes [REDACTED]. Recommend foam dressing (1) to cover skin wounds and honey f/b foam on left foot wounds. Please change BID or PRN when saturated. Secure with soft gauze and use Medi Grip for some compression over all. Will like to see 2 times a week for sharps debridement. Please call to schedule. (Name), RT. (sic)" During an interview on 10/27/14 at 4:45 p.m. staff member W, RN, stated she found the above Wound Care Clinic orders mis-filed. The order was never initiated. She stated this error was found about one and half weeks ago and was reported to the director of nurses. 9/25/14 11:21 p.m. Dressing intact to lower left leg. 9/26/14 02:56 p.m. (sic) checked bilateral lower extremity "scabbed scratches and remaining wounds, 2 + [MEDICAL CONDITION] in legs...no sensation in L foot...malaise today, emesis X 1..." No documentation of the assessment of the resident's BLE was found for 9/27-29/14. 9/30/14 11:01 p.m. "...Patient's left foot is swollen 2 +, left foot is purple/reddish in color, wound is scabbed over but not healing, patient needs to see her doctor as soon as possible for wound on that foot.......pain in left foot and ankle...but not in right foot, which has 3+ [MEDICAL CONDITION] continue to monitor." Review of Treatment sheet dated September 2014 reflected the Duoderm dressings were not being changed every three days as ordered. Dressing changes were completed on 9/11, 9/13, 9/14, 9/19, 9/21, 9/25, 9/26 and 9/30. 10/1/14 9:52 p.m."...has had large mental status change...lungs very congested, wheezing and crackling throughout lobes. O2 SAT was 91 on 2 liters...notified Dr..... and he suggested we send patient to the ER." 10/2/14 01:52 a.m.(sic) Pt is currently oof (out of facility), sent to (name of hospital). Resident was readmitted from the acute care hospital to the facility on [DATE]. Review of the Nursing Progress Notes reflected: On 10/7/14 Return time: 2:45 p.m. Pre-Admission Data: "UTI, [MEDICAL CONDITION] in (lower extremity), [MEDICAL CONDITION], wounds on legs, coccyx red and peri-area red...incontinent of bowel and bladder, pneumonia. 9:12 p.m. Patient has multiple wounds on (lower extremity)...left leg is the worse of her wounds...most of her wounds are scabbed over but need to be dressed with [MEDICATION NAME] and wrapped... will continue to monitor." Review of the Nursing Progress Notes dated 10/8-11/14 did not reflect an assessment of the resident's BLE. A Nursing Progress Note on 10/12/14 at 1:11 p.m. reflects "I removed the dressing from the patient's left ankle. It was saturated through the Polymem with dark gooey drainage. There are three wounds that appear to have grown together into one large wound. A large amount of the skin in the wound is a yellow color. I cleaned the wound as best as I could with NS and applied a non-adherent sterile pad to the area. I then wrapped the foot in curlex (sic), taking extra precautions to make sure that the bandage was not wrapped too tight. [MEDICAL CONDITION] +3 to right lower extremity." On 10/13/14 9:16 p.m. "wounds are the same, seem to not (sic) healing, just staying the same. She did not eat dinner tonight. She did not feel well. Will continue to monitor. Review of the Nursing Progress Notes dated 10/14-18/14 lacked an assessment of the resident's BLE or the notification of the physician concerning the changes documented on 10/12-13/14. On 10/19/14 at 1400, the facility faxed a communication to the doctor, which reflected "Pt has Stasis Ulcers on outside of left foot, wounds are deteriating, would like to use Calcium Alginate and Optional. physician's orders [REDACTED]." The order was noted by nursing on 10/22/14. Another facsimile was sent to the physician 10/19/14 (no time noted) with a request for: Skin treatments order for ulcers on L shin and L foot ulcers (or would you like her to see Wound Clinic again?) The physician responded, "Refer to Wound Clinic." 10/19/14 3:02 p.m. Weekly skin Assessment: Reddened [MEDICAL CONDITION], Skin Problems: has open lesion(s) present in the past seven days. Foot Problems/Care: Has open [MEDICAL CONDITION] on the foot. Left foot. Healing Progress: Worsening. Action: Physician notified. Asked for skin treatment orders. Asked if MD wants her to go to (local) wound care clinic again. 7:53 p.m. Multiple open areas to the outer side of left foot.... Slough....wound tissue is yellow.... moderate exudate..surrounding tissue [MEDICAL CONDITION]. Review of the Nursing Progress Notes dated 10/20-22/14 did not reflect an assessment of the resident's BLE. Review of Physician Telephone Orders dated 10/22/14 6:24 a.m. reflected: Apply Calcium Alginate to the outside of her left foot wounds daily AM. 10/23/14 6:50 p.m. Skin Wound Infection: S/S for wound infection Location:.... This area has multiple wounds that are open and infected. Tissue Type: Slough Necrotic tissue Wound Tissue: Greenish-yellow Surrounding Tissue: [DIAGNOSES REDACTED] present warm, [MEDICAL CONDITION]. Healing Progress: worsening. Description: becoming larger...becoming deeper... sloughing [MEDICAL CONDITION] present at site...tenderness present. 6:58 p.m. Mood: blank Social Life: Reduced social interaction, withdrawn, has the thousand mile stare Social Life: less talkative....isolates self. 10/24/14 06:29 p.m. (sic} skin reddened, dry, cool, [MEDICAL CONDITION], impaired sensation, cyanotic. open area. Has infection of the foot-eg. (sic) [MEDICAL CONDITION], purulent drainage. Has open [MEDICAL CONDITION] on the foot. Receives application of dressings. Skin/wound Infection: S/S infection...Purple/maroon colored, surrounding tissue cooler than adjacent tissue, surrounding tissue mushy/boggy., Slough Necrotic tissue. Wound Tissue: greenish-yellow. Cyanosis noted. Drainage: moderate exudate odorous Surrounding Tissue: [DIAGNOSES REDACTED] present, cyanotic, [MEDICAL CONDITION]. Healing progress: worsening. Changed dressing in/on left foot. 06:36 p.m. (sic) General skin condition: reddened, cyanotic, dry, cold, [MEDICAL CONDITION], impaired sensation....Has infection of the foot-eg. [MEDICAL CONDITION], purulent drainage....has open [MEDICAL CONDITION] of the foot. 9:30 p.m. Patient's lower extremities have 3+ [MEDICAL CONDITION], wounds have continuously declined, wounds have an odor to them. Wounds are covered with a gray (sic) whitish slough. 10/26/14 05:39 (sic} a.m. General Skin Condition: pale, dry, both feet cold. Multiple open area in/on left ankle/foot. Suspected Deep Tissue Injury: Purple /maroon colored, surrounding tissue painful, surrounding tissue mushy/boggy, Appearance of blood-filled blister, surrounding tissue cooler than adjacent tissue, moderate exudate. No odor present. [DIAGNOSES REDACTED] present Healing Progress:Worsening. ....Action: Continue to observe. Encouraged to rest. Repositioned. 10/27/14 No documentation of an assessment of her BLE. 10/28/14 07:26 a.m. Has open [MEDICAL CONDITION] on the foot. Receives application of dressings (with or without topical medication). No change in foot condition as of 10/27/2014. Review of the resident's September Treatments - All Shifts reflected: Entry date: 9/11/14 Apply Duoderm to the 3 [MEDICAL CONDITION] every three days PM (sic)first date: 9/11/14. Review of the documentation area reflected the Duoderm had been applied on 9/11; 9/13; 9/14; 9/19; 9/21; 9/25; 9/26; and 9/30. Review of the Nursing Progress Notes dated 9/13 and 9/14 reflected, "Dr (name) ordered Duoderm for the scabbed red areas on patients (sic) left calf and left foot." This note does not indicate it was a new order or why the change in timing occurred. The notes for 9/19 reflected, "Duoderm applied to wounds," but lacks a reason. The note for 9/21 did not reflect the Duoderm had been changed. The note for 9/25 indicated, "Dressing intact to lower left leg." This was the fourth day from the last application. The note for 9/26 does not reflect a dressing change. The dressing change on 9/30 was the fourth day from the last application. Review of the resident's October 2014 Treatment Sheets - All Shifts reflected, "Entry Date: 10/22/14 Apply Calcium alginate to the outside of her left foot wounds. daily AM first date: 10/22/14. Review of the area that was to be initials when given reflected for 10/22 and 10/23 it had not been initialed as given. 2. Resident #9 was originally admitted to the facility on [DATE] and readmitted on [DATE] with the [DIAGNOSES REDACTED]. The resident's admission MDS dated [DATE] reflected a BIMS score of 15, which indicates the resident is cognitively intact. (BIMS - C0500). Review of the the resident's Treatment Sheet - All Shifts dated August 2014 reflected the following orders: - [MEDICATION NAME] powder to apply topically three times daily, for a skin yeast infection, started 3/14. - Apply Cavalon spray and Elton cream to left upper thigh twice a day, started 4/14. - Ammonium [MEDICATION NAME] 12% lotion topically daily for excessively dry skin, started 8/27/14. The 2014 August Nursing Progress Notes and Treatment-All Sheets record shows no evidence of topical treatment applications on the following dates: - [MEDICATION NAME] mornings treatments - 12th, 28th, 29th; midday - 1st, 5th, 6th, 12th, 13th, 16th, 28th, 30th; evening - 7th. - [MEDICATION NAME] spray and Elton, mornings - 3rd, 4th, 12th; evening - 7th. Review of the the resident's Treatment-All Shifts record dated 9/2014 reflected the following orders: -Apply [MEDICATION NAME] spray and Elton cream to left upper thigh twice a day, started 4/12/14. -Apply thick barrier cream [MEDICATION NAME] to buttocks wounds three times daily and as needed, started 9/15/14. -To skin superior to anal verse (sic) apply thick [MEDICATION NAME] to midline. Apply [MEDICATION NAME] powder to skin surrounding gluteal midline three times daily and as needed, started 9/15/14. -Assess left leg for homeostasis at puncture site and outline [MEDICAL CONDITION] (each shift), started 9/15/14. -Ammonium [MEDICATION NAME] 12% lotion topically daily for excessively dry skin, started 8/27/14. -The weekly skin assessments on bath day, started 2/13/14. The 2014 September Nursing Progress Notes and Treatment - All Shifts Record shows no evidence of topical treatment applications and/or assessments on the following days: - [MEDICATION NAME], mornings - 1st, 4th, 6th, 7th, 13th, midday - 1st, 3rd - 7th, 10th, 11th, 13th, 14th, evenings - 13th, 14th. - [MEDICATION NAME] spray and Elton cream, mornings - 1st, 4th, 6th, 13th, 25th - 2th, evenings - 13th, 14th, 21th, 25th- 29th. - [MEDICATION NAME] to buttocks wounds, mornings - 16th, 25th - 29th; middays and evenings 25th - 28th. - [MEDICATION NAME] to anal verse (sic), mornings - 25th - 29th; middays - 20th, 25th, 26th, 28th; evening - 27th. - Ammonium [MEDICATION NAME] 12% lotion, 1st, 4th, 6th, 7th, 13th, 16th, 26th - 29th. - Assess left leg for homeostasis, 16th, 19th, 22th, 25th -27th, 29th; middays 25th - 27th. - Weekly skin assessments, 7th. Review of the Treatments-All Shifts record dated, October 2014, reflected the following orders: - Apply [MEDICATION NAME] spray and Elton cream to left upper thigh twice a day, started 4/14. - Apply thick barrier cream [MEDICATION NAME] to buttocks wounds three times daily and as needed, started 9/15/14. - To skin superior to anal verse (sic) apply thick [MEDICATION NAME] to midline. Apply [MEDICATION NAME] powder to skin surrounding gluteal midline three times daily as needed, started 9/15/14. - Ammonium [MEDICATION NAME] 12% lotion topically daily for excessively dry skin, started 8/27/14. -Apply daily wet to dry compression to right lower leg, started 10/23/14. The 2014 October Nursing Progress Notes and Treatment- All Shifts-The record lacks evidence of topical treatment applications and/or wet to dry treatments on the following dates: - [MEDICATION NAME] spray and Elton cream, mornings - 1st, 3th, 7th, 11th, 13th, 15th, 18th, 20th, 22th, 25th, 27th; evenings - 2nd, 8th, 12th, 26th, 27th, 28th. - [MEDICATION NAME] to buttocks, mornings - 1st, 3rd, 4th, 7th, 11th, 13th, 15th, 18th, 20th, 22th, 25th, 27th, 28th; middays - 2nd, 8th, 27th, 28th; evening - 1st, 4th, 5th, 16th, 27th, 28th. - [MEDICATION NAME] to anal (verse), mornings - 1st, 3rd, 4th, 7th, 11th, 13th, 15th, 18th, 20th, 22th, 25th, 27th; midday - 2nd, 8th, 17th, 21th, 27th; evenings 1st, 4th, 5th, 11th, 16th, 27th. - Ammonium [MEDICATION NAME] 12% lotion, 1st, 3rd, 7th, 11th, 13th, 15th, 18th, 20th, 22th, 25th, and 27th; (creams were applied on 7 & 13). - Wet to dry compression, 23th - 25th, or 27th. b. Review of the current physician's orders [REDACTED]. Review of the Nursing Progress notes, dated 9/9/14 at 2:07 p.m. reflected, "Orders for D/C bedpan completely and use bedside commode due to skin breakdown, needs to be watched closely and taken off commode as soon as she is done." Review of the Nursing Progress notes dated 9/12/14 at 3:52 p.m. reflected, "Orders remain to not use bedpan, must use commode. Buttocks remain the same." Review of the Nursing Progress Notes dated 9/22/14 at 2:58 p.m. reflected, "Resident has been adhering to instructions not to use the bed pan." Review of the Nursing Progress notes dated from 9/23/14 to 10/28/14 reflected the bedpan use was not addressed again. In an interview on 10/27/14 at 3:25 p.m., staff member U, CNA, stated resident #9 could roll side to side to use the bed pan. She said it was the resident decision to choose the bedpan or get up to use the bedside commode. Delegation of Topical medications: [REDACTED] In an interview on 10/28/14 at 12:00 p.m., staff member O, CNA, stated she had applied creams and powders to resident #9 before she is out of bed, and the barrier creams while she is on the toilet. She said she knew that application of the medicated creams and powders were the nurses' responsibility but that the nurses did not always have the time. In an interview on 10/30/14 at 1:15 p.m., resident #9 said stated that both CNAs train other CNAs and the nurses train CNAs on her medicated topical treatments. In an interview on 10/30/14 at 1:35 p.m., staff member I, RN, stated she did delegate medicated creams and powders with some CNAs that she trusts. She stated she does not document or use a formal delegation process. In an interview on 10/30/14 at 4:10 p.m., staff member B, DON, stated that the facility does not have a delegation process for topical medications and that the CNAs should not apply these nursing treatment items. Wound Care Orders Were Not Clarified In an interview on 10/30/14 at 5:05 p.m., staff member W, RN, reviewed resident #9's electronic treatment record. She said the record is confusing: 1) The [MEDICATION NAME] spray and Elton cream was ordered for left upper thigh twice a day, but that resident has similar wounds on both thighs. The order for the thigh wound did not have a diagnosis. 2) The order for barrier cream, [MEDICATION NAME] to buttocks, was probably a duplication of the order to apply thick [MEDICATION NAME] to the skin superior to anal verse (sic). The orders for the buttocks did not have a definitive geographic location or diagnosis. 3) The order to apply daily wet to dry compression to right lower leg, does not narrow the geographic area of the wound, and it lacked a diagnosis. 3. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission MDS dated [DATE] reflected a BIMS score of "00" indicating the resident had severely impaired cognition (BIMS -C500). Review of a nursing note dated 10/12/14 reflected, "patient has a red area on his left calf that has been there a while according to the CNA('s). It appears to look like a scrape, but looking at it closely, it isn't. It appears to be healing." On 10/14/14 2:39 P.M. the nursing note reflected, "applied dressing over L skinned shin, weeping, no odor noted, informed skin nurse of situation." On On 10/17/14 8:56 p.m. the nursing note reflected, "open area to left leg...for wound infection of left leg, shine (sic) area left anterior lower leg...shine(sic) wound....clean, but not granulating....reddened, moderate exudate, [MEDICAL CONDITION], no tracts; worsening, becoming larger. cleaned, applied dressing leg. On 10/19/14 5:11 a.m. the nursing note reflected, open area left anterior lower leg; moderate exudate, [DIAGNOSES REDACTED] present, [MEDICAL CONDITION]; worsening, becoming larger; checked, changed, applied dressing, treatment ineffective, continue to observe. 3:15 p.m. warm, [MEDICAL CONDITION], left anterior lower leg, no change, becoming larger; asked MD for skin treatment order. Review of the orders dated 10/21/14 for resident #10 reflected daily wound care on left shin by cleaning with soapy water, carefully dry, then apply Vaseline to open sore. Cover with [MEDICATION NAME], and wrap with Kerlix, start . The orders were received nine days after the wound was identified on 10/12/14. In an interview on 10/30/14 at 4:10 p.m., staff member B, DON, stated the nurses must have orders for wound care that specifies dressing type and frequency of dressing changes. She said a nurse could initially place a dressing without orders until the order was received by the physician. 4. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/29/14, the facility faxed resident #8's physician: "Patient admitted to the facility. Need orders for dressing changes on left elbow." On 10/2/14, the facility received the physician's response for resident #8's wound care orders: "Dressing changes daily as needed with daily wound care." The fax from the physician did not include the type of wound care or the type of dressing changes. No evidence was found in the medical record that the orders were clarified.

Based on record review and interview, the facility failed to ensure residents are free from physical, sexual, mental and verbal abuse from staff and other residents for 1(#1) of 16 samples residents. Furthermore, the facility failed to provide ongoing abuse education to all staff, and one staff member's employee filed lacked documentation of abuse training at orientation. Findings include: A review of the Resident Safety Abuse Statement (see F226); and a review of the Resident Rights Under Federal Law document provided on 10/17/14 at 2:50 p.m. by the facility reflected: 1. Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 resided alone in a room at the very end of the hallway. A review of the Initial Incident Reports for the following four incidents submitted to the State Agency, per facility policy, for resident #1 provided the following information: "a. Initial 24 Hour Report On 5/29/14 resident #1 was sitting by the nursing station. Resident #14 was walking by saying insulting remarks to resident #1 whom nursing states was ignoring resident #14. Nursing escorted resident #14 away from resident #1, however she continued back and kicked resident #1's leg. The plan to prevent further abuse: All staff to continue to keep resident #14 away from resident #1, as resident #1 states resident #14 is always rude to her." "b. Initial 24 Hour Report "On 7/17/14 nursing reported yesterday 7/16/14 that resident #14 was having increased behaviors with staff and that she also pulled resident #1's hair. The plan to prevent further abuse: All staff continue to try to keep the two residents away from one another, as the two residents have had previous altercations." In an interview on 10/29/14 at 3:00 p.m. and again at 4:38 p.m., staff member C, Social Services, was asked to provide documentation of a thorough investigation, including interviews with staff and residents for the above incidents. At 6:15 p.m., staff member C stated she did not have any documentation only the summary provided on the incident report. "c. Initial 24 Hour Report On 9/24/14 (resident name) states (staff name), was inappropriate, 'bullying' resident #1." 5 Day Investigation Results Report: "Outcome of your investigation: After interviewing a number of staff, including CNAs and nursing, along with residents of the floor where (staff member G, LPN) worked, it was decided to have her return to work, but, to another wing of the building. Resident in question, (resident #1), could not give any specific details, but did not want that particular nurse to give her medications or treatments. (Staff member G) will be evaluated, week to week, for the next 60 days by the Director of Nursing as to how she is dealing with the residents of the new wing. This includes visiting with those residents of the area she is working in." A review of the Investigation notes provided by the facility showed the following documentation: An undated review of a statement written by a staff member: (CNA) states that (staff member G) said to resident #1 "If you don't behave you will end up going back to live with your sister who abused you." CNA was coming out of a room [ROOM NUMBER] doors down when she heard this. An undated review of an interview with resident #2: Resident #2 spoke with staff member B, DON, and staff member C, SS, regarding a complaint she wanted to make regarding staff member G. Resident #2 states that on Saturday 9/20/14 at approximately 2200 (10:00 p.m.) she overheard staff member G asking Resident #1 why she was not in bed. She then said "go to the bathroom you big baby" and "quite (sic) crying and do as you are told or you are going to your sisters." Resident #2 stated that she heard Resident #1 crying and stating "I'll run away". Staff member G then responded "I will help you so you could get splattered all over the road." Resident #2 then stated that on Sunday 9/21/14 she also heard staff member G calling Resident #1 stupid and stating "You can't do anything for yourself." Review of hand written interviews conducted with residents lacked the identity of the writer and reflected, Saturday night 10 p.m. - (per resident #2): "(Resident #1) why aren't you in bed?" "Go to the bathroom you big baby" "Quite (sic) crying or you'll go to your sisters" (Resident #1) "I'll run away" Sunday per (resident name) (Staff member G) "you can't do anything for your self" to (resident #1). "She takes my jerky and wings and owes me $5 for the wings," referring to (staff member G). (Resident #9) "She cannot give names currently, states (staff member G) sends residents to there (sic) rooms. She doesn't use gloves and doesn't sanitize her hands then picks at an incision. She pulled a stitch out without gloves." (Resident #16) stated "Staff member G told me that I play w/ my poop or stool and that's a lie. She said it in the hall in front of other people." On 9/24/14 a verbal Employee Warning dated reflected: "Violation of resident rights and unprofessional conduct". The form states that staff member G was previously warned on 9/15/14 at 1415 (2:15 p.m.). On 9/24/14 a written warning reflected: "Violating Infection Control Policy." Both forms were signed by the DON and dated 9/24/14. A review of a hand written, unsigned, document dated 9/20/14 showed: "(Resident #2) asked for her night meds and pain pill, vallume (sic) and the nurse (staff member G) refused to give her those meds. She said that she was too sleepy and that she could have Tylenol. (Resident #2) asked nurse if she would go down and change her dressing, and the nurse said that (resident #2) can wait till she got down that way, that she was last on her list. (Staff member G) told (resident #2) if she couldn't behave that she would end up going back to live with her sister who abused her. (Staff member G) told (resident #16) that he could not come out of his room because he played with his stool and that he most likely would never go home. "So many residents have complaints about her on the NW (northwest) wing. There are certain residents that don't like her and she knows they don't. It seems like she purposely goes in and gets them adgitated (sic) and upset." Additionally on 9/21/14 the above document was amended to include the following: "@ (at) 3:30 (resident #2) was talking to me, she thinks that (staff member G) is refusing to go in her room cause she owes her money. (Resident #2) said that on Wednesday she and (staff member G) went in on hot wings together and (staff member G) was going to pay her back and hasn't yet. (Resident #2) also said (staff member G) goes in there all the time and helps herself to (resident #2's) snacks." A review of a hand written document by staff member T, RN, addressed to the DON reflected: "On Thursday night, (staff member G) told (staff name, LPN) that they did not need no (sic) count because she counted at 1900 with (staff name). I explained that she did need to count again. Staff member G slammed book down and shouted 'OK' (staff name). I told her she needed to step back and count to 10. There was staff and residents present at the time." Staff member T signed the document. A review of a hand written document dated 9/22/14 and signed by staff member M, LPN reflected: "I was told by (resident #9) that (staff member G), the afternoon shift nurse, was picking at her lower leg where she had a biopsy taken a few days earlier. The concern is that the resident stated that (staff member G) was picking at her left leg with her fingernails and picking at the scab with her bare hands. She was not wearing gloves at this time. (Resident #9) also stated that the nurse was not cleansing the IV picc (sic) line with antiseptic wipes before introducing the antibiotic to the lumen, resident stated she also did not see gloves on the nurse. (Resident #9) is asking to talk with (staff member B) about this situation." No documentation regarding any discussion was provided to the surveyor prior to the exit. Review of a summary dated 9/26/14 by staff member A, read, "I visited with (staff member G, LPN), regarding a complaint from a resident who overheard (staff member G) talking derogatory to (resident #1), as to why she was not going to bed in a demeaning manor (sic). Also present were (sic) (CNA name), who served as a witness to the conversation and the DON. I read a quote from a witness to the conversation 'Go to the bathroom you big baby. Quit crying and do as you are told or you are going to your sisters. I'll help you so you can get splattered all over the road." (Staff member G) denied she made those type of comments. 'I never called anyone a baby.' I read another quote from a co-worker regarding another resident (#16). 'You are not to come out of the room because you play with your poop and you will never go home.' (Staff member G) said she did say something to that manor (sic). 'She said she was trying to make (resident #16) understand his situation with his needing to stay in his room at the time due to infection control with [MEDICAL CONDITION].' I asked her why she would make these type of comments to the residents who need our care. She said she knows she is loud and needs to keep it down. I expressed the fact (that) these type(s) of statements can be harmful to the residents and be severe enough to go against her license and her employment. (Staff member G) has a rough approach even though she is smiling all the time. We also discussed her becoming upset with a nurse in counting end of shift narcotics a week ago. She said she did not get upset and knows the importance of counting narcotics. (Staff member B), DON, felt people do become upset about (staff member G) and may mis-interpit (sic) her statements. I asked (staff member G) if she had anything to say about this matter. 'She said she never intended to hurt anyone's feelings and knows better how to present herself while working on the floor.' I told (staff member G) we ((staff member B) and myself (staff member A)) would be discussing the matter and get back to her as to our decision. Following the meeting, (staff member B) feels she like (sic) to keep her on the floor. She knows (staff member G) now understands what she needs to do to present herself in front of the residents and coworkers. I said if we keep (staff member G), she would not be working the same wing again, unless, it is necessary. I asked (staff member B) to discuss the matter of (staff name) with the other nurses before we decide what to do." The facility did not provide any additional information regarding the final decision to allow staff member G to resume working with the residents prior to the exit. During a conference on 10/20/14 at 8:30 p.m., staff member F, Regional Director of Operations, stated all investigations are reviewed at the corporate level. "d. Initial 24 Hour Report On 10/25/14 at 4 am in the morning the Nursing Assistant was doing her rounds and came across resident #4 standing over resident #1 in her recliner. Resident #1 prefers to sleep in her recliner. The aide asked him what he was doing and she noticed resident #1's nightgown up and it appeared he was touching her private area. She told him to get out of resident #1's room and she immediately got the supervisor and they called the police. Nursing stayed with resident #1 and evaluated her and then resident #4 was taken into custody by the Police. Resident #1 was sent to the emergency room for further evaluation." 5 Day Investigation Results Report: (No date on document and the resident name was hand written, the report was hand delivered to surveyors on 10/30/14). "Outcome of your investigation: (Resident #1) continues to visit with other residents, attend social gatherings and has appeared to be as before the incident. (Resident #1) does state she knew (resident #4) prior to being at (facility name). (Resident #1) states he was a 'Boyfriend.' Social Services had CRT (Crisis Relief Counselor) come and visit with (resident #1) and the disposition states she does not appear to be at risk for self harm and is recommended she be monitored more at night. Discussed with Administrator and hourly checks are to begin this evening. (Resident #1) also has a (sic) appt. with her Psychiatrist at (facility name) next week. We are encouraging (resident #1) to move in with another roommate for more company. The outcome of the incident is still underway with the local Police Department." Review of the Nursing Progress Notes dated 10/25/14 at 6:15 a.m., for resident #1 reflected "Pt (patient) was resting in recliner w/eyes closed. CNA was doing rounds @ 0400 (4:00 a.m.) and found this resident in pt's room fingering her. CNA reported that she asked the resident what he was doing and he stated, 'I don't know, playing with her I guess.' CNA immediately came to get me and I went to the pt's room to ask her what happened. In pt's own words, 'I don't want him in here. I'm scared. Keep him out. He put his finger in my privates and touched my breast.' I examined the pt's perineal area and there is minor redness around the area but no evidence of swelling, bleeding, or lacerations. Area is intact. I sat with the pt and listened to her repeat what happened several times. Pt reported that she told him to stop but he did not stop. Police, facility administrator, and DON were immediately notified 0430..." A review of the emergency room evaluation dated 10/24/14 at 11:35 a.m. read, "Chief Complaint Patient presents with alleged sexual assault. HPI (resident name) is a 58 yr (year) female who present with complaint of a sexual assault. The patient resides in a local nursing home and awoke to find him in her room and 'put his fingers in her privates'. The attacker apparently was found in the act by nurses at the nursing home and has confessed to authorities. The patient denies any penile or oral contact other than saying that he tried to kiss her. Physical Exam GU ([MEDICAL CONDITION]) External exam shows 2 vertical areas of excoriation on the inner aspect of the labia minora at the 12:00 position which are consistent with nonaccidental abrasions...another area of excoriation at about the 9 to 10:00 position was visible. Speculum exam revealed areas of abrasion on the roof of the 1st part of the vaginal vault (12:00 position) and as well as another area of abrasion at the 6 to 7:00 position. ED Course & Medical Decision Making The patient was told there were findings on exam consistent with her allegations. Photographs were obtained and other evidence collected by the nurse. Final Impression 1. Sexual assault" On 10/27/14 at 1:06 p.m., in the Nursing Progress Notes: Follow Up of Incident: Other: ER visit for exam of possible assault. Physician Review: [DIAGNOSES REDACTED]. Injury: No apparent injury. Actions: Reported to Primary physician (Dr. name). Review of Social Service notes dated 10/28/14 at 11:08 a.m. reflected, "Late entry from yesterday; visited with (resident #1) and asked if she would like to visit with someone regarding Saturday's event and she stated that she wanted to talk with this writer and proceeded to be very happy and excited to talk about her 'Boyfriend in room [ROOM NUMBER].' (Resident #1 ) also mentioned her old boyfriend was in room [ROOM NUMBER]. (Resident #1) finally agreed to visit with a CRT (Crisis Relief Counselor)." Review of Social Service notes dated 10/29/14 at 7:49 p.m. reflected, "Referred to the northwest nurse that hourly check should begin this evening, beginning at 8pm until daylight. Also was to be noted on the CNA's sheets. Asked nurse (name) to have staff keep a log for now; until we see what corporate wishes. Note: The incident happened on 10/25/14 (4 days earlier)." During a telephone interview on 10/30/14 at 5:00 p.m. staff member D, CNA, stated she was starting to do rounds at approximately 4:00 a.m. She stated she usually starts at the end of the hallway where resident #1's room is located. Resident #1 was sleeping in her chair (a recliner), so she went to help another resident. When she came back to resident #1's room approximately 20-25 minutes later she observed resident #4 bending over resident #1 with his hand moving back and forth very forceful and rough. It looked like his fingers were inside resident #1. When she asked resident #4, "what are you doing?" he stepped back and held up his hands and stated "playing were her I guess". Staff member D stated she immediately got the nurse. Resident #1 was saying "I scared, he touched privates, I scared." Staff member D stated that resident #4 had been awake and wandering all night long, and that he had consumed three mountain dews and four sandwiches. Staff member D stated that resident #1 required female care only, and the other two CNA's on shift with her were male. The other residents would complain about one of the male CNA's and did not want him to provide care for them. She also stated that there were multiple other residents who preferred female care only. A review of Resident #1's MDS with an ARD 6/23/14, showed a BIMS score of 9, and on 9/14/14 the BIMS score was 2. According the the RAI a score of 2 shows severe impairment and a score 9 is moderately impaired. A review of the above dates of the MDS documentation for ADL's for resident #1 reflected she needed extensive assist with all ADL's, except eating. Review of resident #1's Care Plan dated 6/24/14, did not identify resident #1 having behaviors regarding boyfriends. During an interview on 10/30/14 at 12:30 p.m., resident #1 was sitting in her wheelchair watching TV as she started to talk, she immediately moved from one subject to another. She stated she got her foot caught in the door, then stated, "Joe comes in my room, we talk and watch TV, he comes in here all the time. I love Joe, Joe loves me, He pushed me out of room, down hallway to take medicine. I sleep in chair - love my chair. My sister has 20 kids and she doesn't have time for me. I am on my own. I only have Joe, he loves me. I love Butte, Butte is my town. My birthday is November 19th. I have big party. I like rain, I like to swim. My sister took my clothes. I don't know why. I wear diaper. I put them on by myself. I like my chair, it has a pillow in it. My sister took my coat." When asked her if anyone came in her room she started repeating phrases of the above conversation. During an interview on 10/30/14 at 1:10 p.m., staff member I, RN, stated she does not feel that resident #1 can make a competent decision. 2. Resident #4 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Emergency Department report dated 9/19/14 reflected resident #4 was [AGE] years old and had suffered a [MEDICAL CONDITION] at the age of 18. Review of resident #4's MDS with an ARD of 10/3/14 showed his BIMS was 15. According to the RAI, a score of 15 is considered cognitively intact. 3. During an interview on 10/28/14 at 2:05 p.m. with staff member C, Social Services, stated that during new employee orientation, each department does an overview and Social Services goes over Resident Rights and Abuse. She stated that she does annual abuse training for the employees which is mandatory, and the employees have a choice of two days to attend. Review of an Employee In-service Attendance Record dated 8/4/13 at 1:45 p.m. reflected staff members A, B, and C presented an in-service on resident abuse and neglect, communication to residents and families and care plan process. Seventeen CNA's and seven licensed nurses attended the in-service. Two CNA's were from the night shift and staff member G, LPN did not attend. Review of an Employee In-service Attendance Record dated 9/23/14 and 9/24/14 at 1:45 p.m. reflected staff member C presented an inservice on resident rights, abuse, reporting suspected allegations, phone privacy and more topics. Staff member C stated this training was to include all staff. Twenty CNA staff attended, one was from the night shift. Four licensed nurses attended for a total of 24 out of 46 direct patient care staff. Nine non nursing staff attended. Review of the documentation provided by the facility showed they have 29 CNA staff and 17 licensed nursing staff. During an interview on 10/28/14 at 3:00 p.m. staff member C stated she held the in-service for two days and the staff needed to attend one of the sessions. 4. A review of staff member L's, CNA, General Orientation Outline, showed the form was not signed by the staff member or the supervisor and was not dated.

Based on record review and staff interview, the facility failed to promote the prevention and healing of pressure ulcers for 1 (#6) of 15 sampled residents. The facility failed to evaluate the residents' clinical condition and pressure ulcer risk factors; define and implement interventions timely, or monitor and evaluate the impact of the interventions as appropriate. Findings include: Resident #6 was re-admitted on [DATE]; [DIAGNOSES REDACTED]. According to the MDS annual assessment with an ARD of 8/28/12, the resident needed total assistance with bed mobility and transfer (G0110A,B). She had no significant weight loss (K0300) and no nutritional approaches (K0500). She was at risk for pressure ulcer development (M0150) and had a stage 4 or greater pressure ulcer, noted from the formal assessment tool and clinical assessment (M0100B,C). The number of pressure sores on admission was 0 (M0300D). Skin and ulcer treatment included a pressure reducing device for chair, pressure reducing device for bed, turning and reposition program, ulcer care, and nonsurgical dressing (M1200). Assessment: The following Nursing Progress Notes depicted the status of the resident's skin related to the presence of pressure ulcers: -7/16/12, an unknown area measuring 1.5 cm diameter was documented. Noted as a Stage II pressure sore. -7/31/12, the "right anterior thigh/pelvis" area was measured at 1 cm x 1 cm x 0.2 cm. Stage II pressure sore. -8/2/12, the "right mid buttock" area was measured at 2 cm x 1.5 cm x 0.2 cm in depth. Stage III pressure sore. Physician was notified of worsening symptoms. New orders received for dressing. -8/21/12, the "right anterior thigh/pelvis" area was measured at 1.5 cm x 2 cm x 0.5 cm. Stage IV pressure sore. The physician was notified. -8/28/12, the "right upper buttock hip" area was measured at 1.5 cm x 1.5 cm x 0.4 cm. Stage IV pressure sore. -9/13/12, the "right hip" area was measured at 1.5 cm x 2.5 cm x 2 cm. Stage IV pressure sore. -9/16/12, the "right mid coccyx" area was measured at 1 cm x 0.75 slough. "Pallor noted heavy exudate". Stage IV pressure sore. -9/19/12, the "R hip" area was measured at 1.5 cm x 2.5 cm x 2 cm. SINUS TRACTS/UNDERMINING: Present Location: 3 o'clock Depth: 5 cm . . . worsening . . . " Stage IV pressure sore. -9/24/12, the "R hip" area was measured at 1.5 cm x 2 cm x 2 cm. Undermining Depth: 5 cm "no change" Stage IV pressure sore. -9/27/12, the "R hip" area was measured at 1.5 cm x 1.5 cm x 2 cm. Undermining Depth 5.5 "worsening" Stage IV pressure sore. -9/30/12, the "right anterior thigh/pelvis" area was measured at 2 cm x 2 cm x 5.25 cm. Stage III pressure sore. -10/12/12, the "R hip" area was measured at 1 cm x 0.5 cm x 6 cm. Stage IV pressure sore. -10/18/12, the "right anterior thigh/pelvis" area measured at 1 cm x 1 cm x 5 cm. Not staged. -10/27/12, the "hip" area measured at 5.5 cm x 1.5 cm x 2.5 cm. Undermining present but not measured. Not staged. -10/31/12, the "right upper buttock, right anterior thigh/pelvis" area measured at 1.5 cm x 2 cm x 0.6 cm. Undermining Depth 6 cm. Stage III pressure sore. -11/3/12, the "right upper buttock, right anterior thigh/pelvis" area measured at 1.5 cm x 2 cm x 5.5 cm. Not staged. On 11/8/12, the DON was asked to verify the location of the pressure sore as more than one area was documented on the skin assessment sheets. The DON stated there was only one pressure sore that was on the right hip. The following Skin Care Flow Sheets depicted the status of the resident's skin related to the presence of pressure ulcers: 8/2/12, the "R Buttock" area was measured at 2 cm x 1.5 cm. Stage III pressure sore. -8/7/12, the "R Buttock" area was measured at 1.5 cm x 1 cm x 0.1 cm. Stage II - III pressure sore. -8/15/12, the "R hip" area was measured at 1.5 cm x 2 cm x 0.1 cm. Stage II pressure sore. -8/18/12, the "R hip" area was measured at 2 cm x 1 cm x 0.6 cm. Stage II pressure sore. -8/19/12, the "R hip" area was measured at 2 cm x 1.8 cm x 1.5 cm. Stage II pressure sore. -8/21/12, the "R hip" area was measured at 1.5 cm x 1.5 cm x 1.5 cm. Stage II pressure sore. No drainage, no odor, "beefy red, clean, full thickness". -8/21/12, the "Rt hip" area was documented as, "moderate amount drainage, yellow eschar, some granulation". Stage II pressure sore. -9/21/12, the "R hip" area was measured at "2 cm circular - 2" deep". Stage III pressure sore. -9/30/12, the "R hip" area was measured at "2 cm circular - 5 1/4 cm deep". Stage III pressure sore. -10/29/12, the "R" hip area was not measured. Documented as Stage III pressure sore. On 11/7/12 at 2:00 p.m., staff member R, LPN , was interviewed. She stated she thought the new skin protocol had started. There was a book at the nurses' station that would be used. She was unsure of who would be doing the skin checks as she had not heard. Staff member R opened the skin book and stated, "well it is empty so I guess it hasn't started yet". On 11/8/12 at 7:40 a.m., staff member K, RN, was interviewed. She stated the nurses on the floor used to do the skin assessments and wound care, but it was not specific to a certain nurse or a certain time. "Which ever nurse has time will do the assessments and treatment of [REDACTED]. She further stated she was unsure who was now responsible for wound care. On 11/8/12 at 8:10 a.m., staff member J, LPN, Patient Care Coordinator was interviewed. She stated staff should be assessing pressure sores weekly, which would include measurements and staging. She was aware that the staff may not be assessing pressure sores appropriately and had recently started a new program to address skin issues. She had not had a chance to train all nursing staff on the new skin protocol. She also stated that residents needing assistance with bed mobility, such as turning every two hours, had been a concern. She was working on a solution for that problem. She further stated she would be monitoring skin weekly including pressure sores. The Nursing Progress Notes and Skin Care Flow Sheet were inconsistent and inaccurate. On 8/21/12, the pressure sore was assessed by three facility staff. The pressure sore had been staged on 8/21/12 as a II and a IV. Further, the DON had to clarify that there was only one pressure sore, as the area of the sore was documented differently by staff. It was difficult to assess through chart review at what stage the pressure sore was at due to the inconsistencies. Interventions: a. On 8/27/12, the dietician reviewed the resident's intake and recommended vitamin C, MCI with mineral, and zinc sulfate to assist pressure sore healing. -On 10/25/12, three months after the pressure sore was noted, nursing sent a request to the physician requesting vitamin C, MCI with mineral, and zinc sulfate. This had been requested from the dietician two months prior. b. On 8/27/12, the resident was seen by the physician. The physician wrote on Physician's Progress Notes, "Stage IV Decubitis . . . Debrided . . . ". The physician further wrote on the Doctor's Order Sheet, "Roho Cushion, Air Mattress overlay". -On 8/28/12, a Roho cushion was placed in the resident's wheelchair and an air mattress applied to the bed. -Pressure sore relieving devices were not initiated until six weeks after the initial pressure sore was noted. c. On 9/7/12 at 4:12 p.m., the physical therapist signed the Initial Assessment of resident #6. The therapist wrote, "She also has a decubiti on her R hip secondary to positioning on her side in bed". -On 10/18/12 at 1:02 p.m., the Nursing Note documented, "Has area to right hip from 7/16/12 from wheelchair rib (sic) changed multiple different wheelchairs to find a good fit, cushion to w/c, special bed turn q two hours. was treated with ca argenate and opsite was almost healed. Doctor did surgical debridement and patient had a tunneled wound and started on wound vac. At this time changed q 48 hours. Infection contact precautions". -On 11/8/12 at 4:50 p.m., the medical director was interviewed. He stated pressure sores had been discussed during the Quality Assurance meetings. He further stated he discussed the need for facility staff to monitor behavior of a resident with a pressure sore so as to determine how a pressure sore developed. The medical director felt that it would be unlikely the facility staff could heal a pressure sore without determining the cause first. -There were inconsistencies related to how the resident received the pressure sore. The resident developed a pressure ulcer that over the course of approximately 3 months had been inconsistently evaluated and monitored by the licensed nurses, and the pressure ulcer had progressed to a stage IV. The clinical record lacked documentation of clearly defined treatment interventions and objective goals to determine if the treatment interventions were effective.

Based on record review, policy review, and staff interview, the facility failed to ensure the resident's physician's orders? and the facility's policy and procedure on wound care were followed to ensure the resident received timely medical care for 1 (#1) of 15 sampled residents. Findings include: Resident #1 had been admitted on [DATE] from the hospital following a fall and open reduction-internal fixation of left bimalleolar ankle fracture on 8/1/12. She was then sent to the ED and admitted to the hospital on [DATE] due to left ankle smelling foul and the wound being open. The resident was re-admitted on [DATE] to the facility following repair of the left ankle which had wound dehiscence with infection. Review of resident #1's 8/20/12 Care Plan on 11/8/12 indicated under the "Problem: Tissue integrity impairment, related to recent ankle surgery included the goal for the wound to heal without signs/symptoms of infection. "Approaches" included "Nurses - assess skin status, weekly and per MD orders for wound care. Nurses - keep MD informed of any changes. Nurses -monitor for s/s of infection at surgical wound and report findings immediately to the MD. Nurse Aide - assist to turn and reposition her every two hours and prn. and keep the boot on her left ankle/foot at all times except during bathing". Review on 11/8/12 of the discharge instructions from the hospital dated 8/8/12 included keeping the wound/cast clean and dry and the wound elevated. These instructions included an appointment with orthopedic surgeon on 8/17/12. Review of the 8/17/12 "(orthopedic office) MD/Nurse Notes: The patient doing well two weeks status [REDACTED]. Plan: At this time the patient will remain nonweightbearing on the left lower extremity. We did put her in a fracture boot today and have instructed the nursing facility for her to wear that at all times excepts (sic) when she showers. She was (sic) some mild serosanguinous (sic)drainage from her medial incision, so we have requested daily wound checks on her incision sites. Staples were removed and Steri-Strips were placed. Follow-Up: We will see the patient back in four weeks with repeat views of the left ankle, or sooner should there be problems." Review of the 8/17/12 Doctor's Order Sheet from the orthopedist indicated "1. NWB on L (circled) 2. Follow up (name of orthopedic surgeon) in 4 weeks 3. Boot on at all times except to shower. 4. Daily wound check 5. Elevate L (circled) LE when resting." Review of the Treatment Record for 8/12 indicated "PRN elevation and/or ice wound prn for comfort. This was documented one time a day beginning 8/8/12 but was not documented on 8/18, 19, 25, 26 and 28/12. This documentation did not distinguish whether it was for elevation or ice being applied. The Treatment Record also indicated "Elevate LLE when resting NWB LLE 8/17/12." There was no initialing/documenting whether this had been done. The Treatment Record also included daily wound checks which was not documented for 8/19, 8/25 and 8/26/12. Additionally, the Treatment Record included an area for documenting the boot being on at all times. Review of the Treatment record indicated no evidence of initialing/documentation on the treatment record for the completion of the boot on at all times for all days in August. Review of the facility's Policies and Procedures Nursing Skin Treatment Management Protocol indicated under the heading of "Classification Surgical wound" then "Treatment Protocol" included "Complete initial wound assessment in ECS Weekly Wound Charting folder, and set up for weekly re-assessment and documentation through end of healing plus 4 weeks. Monitor for risk of infection - fever, inflammation, chills/diaphoresis - will typically occur by third post-operative day." Under the heading of "Topical/Dressings" it indicated "Most surgical wounds require some type of dressing for protection and should be guarded against trauma and risk for infection minimized." Under the heading of Documentation, it included "Dimensions: Always measure length, width, and depth and document in that order.Wound description, Drainage: Amount; Color/Consistency (serous, serosanguinous, purulent); Odor(if present or not); Healing progress: Improved, no change/stable, declined." The protocol also included the reference "Interventions & Clinical Skills; Elkin, Perry & Potter, 3rd Edition: Providing Surgical Wound Care, pp 536-551." During an interview with staff member S, RN, on 11/8/12 at 9:15 a.m., staff member S stated, "Have to agree, I am not seeing documentation of these orders for 8/17/12 being followed. The boot being on continuously was not documented. I have been telling them I didn't find wound checks being done daily. Didn't do anything til 8/27/12." Staff member S provided the nurses notes, per the surveyor's request, of what documents staff member S had reviewed to reach the conclusion for the facility's lack of documentation. Review of nurses notes for the month of August indicated documentation with regards to the left ankle on 8/26, 8/27 and 8/31/12. Review of the 8/26/12 entry indicated "(resident #1) appeared more confused tonight she sat up on the side of her bed for quite awhile this shift, she was upset about having to wear the boot on her left leg." Review of the 8/27/12 entry indicated "Resident was awake at 0100 (1 a.m.), crawling OOB (out of bed) and requesting her boot be removed which is on her right (sic) lower leg. Resident medicated for pain with 1 [MEDICATION NAME] per PRN orders and right (sic) lower leg assessed to be rubor, swollen, and red to the touch, with a small amount of serisangenous (sic) drainage noted to resident sock...Resident has been running a low grad (sic) temp this shift...." Review of the 8/31/12 entry indicated "Wound to Left ankle smelling foul and open. On-call MD ordered to send to ER for evaluation and treatment." There was no other evidence of documenting daily wound checks, elevation, notifying the doctor prior to 8/31/12 nor the wearing of a boot. Review on 11/8/12 of the 8/31/12 Physical Evaluation to the hospital indicated : "There is [DIAGNOSES REDACTED] extending from the left ankle halfway up the left calf. There is an open wound of the left lateral malleolus with exposed hardware." ?As stated in Fundamentals of Nursing by Sue DeLaune and Patricia Ladner, the following was noted: "In accord with their nursing practice act, nurses are obligated to follow the orders of a licensed physician or other designated health care provider unless the orders would result in client harm. The nurse has a legal responsibility to the client to ensure that the order is clear and appropriate to the client's treatment. When the nurse queries a physician order, the physician should be contacted to obtain clarification." Fundamentals of Nursing. DeLaune, S and Ladner, P. Delmar, 2002, p. 467