Every finding on record at Falcon Heights Rehabilitation and Nursing LLC

Based on observations, record review, and interviews, the facility failed to ensure two (#62 and #80) of eight residents reviewed for abuse out of 42 sample residents were kept free from physical abuse.Resident #80 was admitted on [DATE] with a diagnosis of dementia. Resident #80 resided in the memory care unit. On 5/13/26, Resident #80 was ambulating through the secured unit when Resident #10 approached her from behind and pushed her. Resident #80 fell to the ground and sustained a laceration to her left eyebrow measuring 1.4 centimeters (cm) by 0.2 cm, a skin tear to her left forearm measuring 6 cm by 0.4 cm and she had significant swelling and bruising to her left finger. Resident #80 was transferred to the hospital and received stitches to her left eyebrow.Additionally, Resident #62 was pushed by Resident #10 on 5/28/26, which caused Resident #62 to fall to the ground.Specifically, the facility failed to:-Protect Resident #80 from physical abuse by Resident #10; and,-Protect Resident #62 from physical abuse by Resident #10.Findings include:I. Facility policy and procedureThe Abuse, Neglect, and Exploitation policy, implemented 4/11/25, was provided by regional clinical resource #1 on 7/23/26. It read in pertinent part, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.II. Incident of physical abuse by Resident #10 towards Resident #80 on 5/13/26A. Facility investigationThe 5/13/26 facility investigation was provided by the operations manager on 7/21/26 at approximately 2:00 p.m. The investigation documented that on 5/13/26, certified nurse aid (CNA) #7, who was assisting another resident on the memory care unit, observed Resident #10 approach Resident #80 from behind and push Resident #80 against the wall. The investigation documented CNA #7 reported that it seemed there was no reason Resident #10 pushed Resident #80. The investigation documented Resident #80 lost her balance, hit the left side of her head against the handrail, and fell to the ground. The investigation documented CNA #7 and the nurse on duty were interviewed immediately after the incident. The investigation documented Resident #10 was diagnosed with vascular dementia with behavioral disturbances on 5/6/26. The investigation documented Resident #80's electronic medical record (EMR) was reviewed and it was identified that she was vulnerable due to muscle weakness, gait abnormalities and lack of coordination. The investigation documented Resident #80 was assessed and sustained a laceration to her left eyebrow measuring 1.4 cm by 0.2 cm, a skin tear to her left forearm measuring 6 cm by 0.4 cm and she had significant swelling and bruising to her left finger. She complained of a headache and hip pain. The investigation documented there was no apparent external injury to the resident's hip. Resident #80 was hospitalized and received stitches on her left eyebrow area. Upon return from the hospital, Resident #80 was moved to a different hallway for her safety. The investigation documented Resident #10 was transferred to the hospital two days after the incident. Hospital diagnostic data revealed Resident #10's blood sugar was increased. The investigation documented the resident's increased blood sugar was clinically proven to induce acute delirium, severe confusion and unprovoked physical agitation in residents with underlying dementia. Resident #10 was placed on 15-minute checks.The investigation documented the facility attempted to interview Resident #10 and Resident #80 following the incident, but neither resident was able to recall the incident. The investigation concluded that Resident #10 hit Resident #80 from behind without being provoked.B. Resident #10 (assailant)1. Resident statusResident #10, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included type 2 diabetes, dementia without behavioral disturbance, vascular dementia with behavioral disturbance, and mood disorder. The 5/27/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. He needed setup assistance with eating and toileting. He needed moderate assistance with bathing, dressing, and oral hygiene. The assessment documented the resident did not have any behaviors directed towards others. 2. Record reviewThe elopement care plan, revised 6/17/26, revealed Resident #10 was at risk for wandering related to the new environment. Pertinent interventions included the resident had a wanderguard on his left wrist and was with a one a one-to-one caregiver at all times. The physical altercation care plan, revised 5/26/26, revealed Resident #10 was the initiator of a physical altercation with another resident. Pertinent interventions included administering medications as ordered and moving the resident off of the secured unit (see incident below with Resident #62).C. Resident #80 (victim)1. Resident statusResident #80, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2026 CPO, diagnoses included dementia with behavioral disturbance, lack of coordination, and abnormalities of gait and mobility. The 6/11/26 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of seven out of 15. She required set up assistance with all activities of daily living (ADL). The assessment documented the resident did not have behaviors directed at others or wandering behaviors. 2. Resident interviewResident #80 was interviewed on 7/21/26 at 12:45 p.m. Resident #80 said she did not remember the incident with Resident #10. She said she thought there was one female resident who was mean to her, but she did not remember what happened exactly. 3. Record reviewResident #80`s elopement care plan, initiated 3/9/26, documented that she had elopement attempts and wore a wanderguard. Pertinent interventions included providing activities, and monitoring her safety.The victim/aggressor care plan, initiated 7/21/26, revealed Resident #80 was the victim of an altercation with another resident. Pertinent interventions included administering medication as ordered, providing one-on-one monitoring as needed, and offering psychosocial support as needed.III. Incident of physical abuse by Resident #10 towards Resident #62 on 5/28/26A. Facility investigationThe 5/28/26 facility investigation was provided by the operations manager on 7/21/26 at approximately 2:00 p.m. The investigation documented that on 5/28/26 at approximately 1:20 p.m., an incident occurred between Resident #10 and Resident #62. The investigation documented Resident #62 was engaging in his typical pacing patterns throughout the unit when he approached Resident #10, who was seated eating a snack. The investigation documented Resident #62, who had severe cognitive deficits, reached towards Resident #10's tray. The investigation documented Resident #10 reacted defensively and impulsively to the invasion of his personal space. The investigation documented Resident #10 reached out and pushed Resident #62, which caused Resident #62 to fall to the ground. The investigation documented the incident was witnessed by CNA #8.The investigation documented CNA #8 was interviewed. CNA #8 said he was in the dining room and saw Resident #62 pacing. He said Resident #62 approach Resident #10 and reach for his (Resident #10) snack. CNA #8 said before he could intervene, Resident #10 defensively pushed Resident #62. He said Resident #62 fell backwards. CNA #8 said he immediately separated the residents. The investigation documented the nurse on duty was interviewed and said she rushed to the dining room when she was notified of the incident. She said she completed an assessment of Resident #62 and noted minor arm abrasions on the resident.The investigation documented the residents were immediately separated. Resident #10 was escorted to his room and placed on 15-minute checks and later changed to one-to-one care. Resident #10 was also moved off the secured unit within the hour and was assigned a private room. The resident was provided a wanderguard. The investigation documented Resident #62 was assessed by the nurse. Resident #62 sustained three small abrasions on the back of his right arm above his elbow. The investigation documented Resident #62 might have hit his head, per the staff. There were no signs of injury and neurological checks were initiated and within normal limits. The resident had full range of motion and was able to walk around the unit on his own following the assessment. The investigation documented Resident #62 and Resident #10 did not recall the incident.The investigation concluded this was an isolated resident-to-resident environmental interaction related to the resident's dementia. B. Resident #62 (victim)1. Resident statusResident #62, age [AGE], was admitted on [DATE]. According to the July 2026 CPO, diagnoses included Alzheimer`s disease and vascular dementia with mood disturbances. The 6/18/26 MDS assessment revealed the resident had a memory problem and was severely impaired, per staff assessment. Resident #62 required set up assistance with eating, oral hygiene, toileting, bathing, and dressing. The assessment indicated the resident did not have wandering behaviors. 2. Record reviewResident #62`s wandering care plan, initiated 6/25/25, documented the resident required placement on a secure unit due to dementia, elopement attempts, and exit-seeking behavior. Pertinent interventions included offering activities, redirecting the resident with snacks or beverages and distracting the resident by offering pleasant diversions.The victim care plan, initiated 5/29/26, documented Resident #62 had the potential to be a victim of physical aggression due to dementia and poor impulse control. He was at risk due to impaired cognitive function.IV. Staff interviewsRegistered nurse (RN) #1 was interviewed on 7/22/26 at 2:30 p.m. RN #1 said Resident #62 routinely wandered between his room and the dining room during meal times. She said Resident #62 would attempt to take food or drink from other residents. A staff member, who wished to remain anonymous, was interviewed on 7/23/26 at 9:00 a.m. The staff member said that he was not present during the occurrence between Resident #10 and Resident #80 and learned about it afterward. The staff member said Resident #10 did not have a history of aggressive behavior before the incident on 5/13/26. He said Resident #10 was protective of his personal space and belongings. The staff member said the staff did not recognize this until after the incident on 5/13/26. He said Resident #10 stayed to himself most of the time. He said Resident #10 was placed on 15-minute checks, but he could not recall all of the interventions implemented. He said he did not recall whether Resident #10 was placed on one-on-one supervision following the incident with Resident #80. He said Resident #10 frequently ambulated throughout the unit, but did not enter other residents' rooms. He said Resident #10 did not present with aggressive behavior towards others before the incident between Resident #10 and Resident #80. The staff member said Resident #62 had a history of wandering and attempting to take food and belongings from other residents. He said Resident #62 approached Resident #10 (on 5/28/26) in the dining room while Resident #10 was eating lunch and attempted to take food from Resident #10. The staff member said Resident #10 stood up and pushed Resident #62, causing him to fall. The staff member said the incident occurred too quickly for staff to intervene. He said the other CNA on the shift was entering the dining room when the incident happened. He said the other CNA was watching the hallway during the meal and the nurse was at the nurses' station. He said the incident was a surprise for the staff. He said the staff was worried that Resident #10 would act aggressively again and they would not be able to stop him. He said Resident #10 was moved off of the memory care unit after the incident on 5/28/26. He said if abuse or an emergency happened, he would report to the nurse directly. He said the abuse coordinator for the facility was the assistant director of nursing (ADON). Another staff member, who wished to remain anonymous, was interviewed on 7/23/26 at 10:00 a.m. She said Resident #10 had not exhibited aggressive behavior prior to the incident involving Resident #80 on 5/13/26. She said she could not recall the interventions that were put in place for the residents after the incident. She said she positioned herself in front of Resident #10 whenever Resident #10 needed to be redirected. A third staff member, who wished to remain anonymous, was interviewed on 7/23/26 at 10:30 a.m. He said Resident #10 had not exhibited physical aggression towards others prior to the incident involving Resident #80. He said Resident #10 and Resident #62 did not get along and frequently bickered while on the unit. RN #3 was interviewed on 7/23/26 at 12:30 p.m. RN #3 said she was on her lunch break during the incident involving Resident #10 and Resident #80. She said Resident #10 had not exhibited aggressive behaviors prior to the incident on 5/13/26. She said Resident #10 was docile, easily redirected, and did not have a history of altercations with residents or staff. She said Resident #10 was placed on 15-minute checks following the incident and exhibited no concerning behaviors during the monitoring period. RN #3 said the incident between Resident #10 and Resident #62 happened too fast and the staff could not anticipate or prevent it. She said the staff were aware of Resident #62's tendency to take other residents' belongings and food, but the incident with Resident #10 happened too fast. She said the staff was a foot away from Resident #62 but was not able to prevent the physical abuse. The director of nursing (DON) was interviewed on 7/23/26 at 1:30 p.m. The DON said interventions for residents who wandered included offering snacks, favorite foods, and time in the television room. She said there were no residents on the unit requiring a higher level of care and said the residents were all somewhat independent. The DON said after the incident with Resident #80, the medication review for Resident #10 identified the resident had hyperglycemia, with a blood sugar level of 600 milligrams/deciliter (mg/dl), which the facility believed contributed to Resident #10`s behavior. The DON said Resident #62 wandered excessively throughout the unit.The DON said Resident #10`s protectiveness over food was not recognized until after the incident involving Resident #62. She said the facility was unaware of this behavior before Resident #10`s admission. The DON said said Resident #10 resided in the memory care unit because of his wandering behaviors. She said Resident #10 was moved off the unit temporarily. Resident #10 was placed on 15 minute safety checks and received a medication review. The DON said Resident #10`s previous facility reported the resident had prior behavioral incidents, but he had had no additional aggressive behavior for several years before his admission to the current facility. She said Resident #62 had a history of entering other residents' rooms and taking their belongings. She said the facility was aware of Resident #10's possessive behavior and his blood sugar problems before the occurrence with Resident #62. She said resident #62's wandering put him at risk of being a victim. She said offering snacks for Resident #62 was an intervention prior to the incident. The DON said Resident #10 was placed on one-on-one monitoring following the incident. She said Resident #10`s behavior was reviewed during the interdisciplinary team (IDT) meeting. She said she was unsure if Resident #10 had hyperglycemia at the time of the incident with Resident #62. She said Resident #10 was permanently removed from the memory care unit following the incident with Resident #62 because he was not actively wandering or exit-seeking. She said Resident #10 wore a wander guard after being moved off the unit. The DON said the facility increased activities for the residents after the second incident on 5/28/26. She said the facility extended the activities until 8:00 p.m.

Based on record review and interviews, the facility failed to ensure professional staff was licensed, certified, or registered in accordance with applicable state laws.Specifically, the facility failed to ensure the acting nursing home administrator's license was current.Findings include:I. Facility policy and procedureThe Licensed Nursing Home Administrator policy, [DATE], was provided by regional clinical resource #2 on [DATE] at 10:39 a.m. It read in pertinent part, The facility shall be operated under the direction and oversight of a qualified and appropriately licensed Nursing Home Administrator in accordance with applicable federal and state requirements. The Administrator shall: Maintain a current and valid nursing home administrator license as required by applicable state law; meet all applicable federal and state licensure and qualification requirements; maintain required continuing education and professional development; practice within the scope of applicable laws and regulations; notify the appropriate licensing authority of any change in licensure status when required; and, maintain knowledge of current CMS (Centers for Medicare and Medicaid services) requirements, state regulations, life safety code requirements, infection prevention standards, and other applicable regulatory requirements.II. Entrance interviewOn [DATE] at 8:18 a.m. the entrance conference was conducted with the facility operations manager. The operations manager said the director of nursing (DON) was acting as the nursing facility's administrator (NHA) at the time of the survey.III. Record reviewOn [DATE] at 2:00 p.m. a review was conducted on the state licensing website. The website revealed the DON was issued an NHA temporary permit for emergency situations on [DATE], but the temporary license had expired as of [DATE].IV. Staff interviewsRegional clinical resource #1 and the operations manager were interviewed on [DATE] at 2:12 p.m. Regional clinical resource #1 said the facility found out on [DATE] (during the survey) that the DON's temporary NHA license had expired and the DON submitted to renew the license (on [DATE]). She said the DON reapplied for a temporary NHA license and the facility heard back from the state licensing agency that the DON would be updated within 48 hours.The operations manager said he had been handling the day to day operations of the facility and consulting with the DON as she was the acting NHA.The DON (acting NHA) was interviewed on [DATE] at 12:05 p.m. The DON said she was the NHA and the previous NHA position became vacant in [DATE]. The DON said she was asked to apply for a temporary NHA license and received the license the same day. She said she thought her temporary NHA license expired on [DATE].V. Facility follow upOn [DATE] a review was conducted on the state licensing website. The website revealed the DON was issued a NHA temporary permit for emergency situations on [DATE] (during the survey) and effective on [DATE] with an expiration date of [DATE].

Based on observations and interviews, the facility failed to store, prepare and distribute food in a sanitary manner in the main kitchen.Specifically, the facility failed to:-Ensure potentially hazardous foods were properly dated and labeled;-Ensure non food contact surfaces were smooth, cleanable and free of debris; -Ensure ready to eat food was kept off the floor; and,-Ensure food in the steam table was protected from dust on the light cover above it.Findings include:I. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 7/28/26 read in pertinent part, Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees fahrenheit (F) or less for a maximum of seven days. The day of preparation shall be counted as day 1. (3-501.17) Food shall be protected from contamination by storing the food: In a clean, dry location; where it is not exposed to splash, dust, or other contamination; and at least six inches above the floor. (3-305.11) Nonfood-contact surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. (4-202.16) Floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. (6-201.11) Physical facilities shall be maintained in good repair and physical facilities shall be cleaned as often as necessary to keep them clean. except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of food is exposed such as after closing. (6-501.11-12)II. Facility policy and procedureThe Food Safety Requirements policy, May 2026, was provided by regional clinical resource #2 on 7/23/26 at 10:49 a.m It read in pertinent part, It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be served in accordance with professional standards of food safety. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following: Procurement (obtaining) of food from sources approved or considered satisfactory by federal, state, and local authorities; storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms; preparation of food, including thawing, cooking, cooling, holding, and reheating. Distribution and service of food to the resident, including transportation, set up, and assistance; equipment used in the handling of food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with food; and employee hygienic practices. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. Keep foods/beverages in a clean, dry area off the floor and clear of ceiling sprinklers, sewer/waste disposal pipes, and vents.Foods that require refrigeration shall be refrigerated immediately upon receipt or placed in the freezer, whichever is applicable. Practices to maintain safe refrigerated storage include labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded.III. ObservationsA kitchen walk through was conducted on 7/20/26 at 7:10 a.m. The following was observed:The dish room had two side by side entrances from inside the main kitchen. A piece of FRP (fiberglass reinforced panels) was missing from one side of each door frame, leaving multiple dried pieces of glue exposed on the wall. The wall and floor under the dirty side of the dish machine had multiple pieces of crumbs and debris. The walls beneath the dish tables surrounding the dish machine were covered with gray streaks and spots running down them. There were four to five flies hovering around the large trach receptacle in the dish room. Behind the trash receptacle on the wall between the two open doors, was brown and orange pieces of food debris dried and stuck to the wall covering an area approximately one by three feet.There was debris and food crumbs under a prep table in the back of the kitchen. On the wall behind a second preparation table was a rough and textured wall with pieces of tan and brown food debris stuck to it. Some pain on the wall had peeled off revealing the texture underneath. There were grooves and dents in the wall where the edges of the table touched the wall, approximately a quarter inch deep and ten to twelve inches long.To the left and right of the walk-in refrigerator there was a gap between the external walk-in wall and kitchen wall more than a foot wide. Pieces of trash and debris were on the floor on each side of the door.On the kitchen wall next to the reach in behind the table were dents in the wall and the outer layer of the wall was peeling off.There was visible dust and lint on a light cover above the steam table in the kitchen that held uncovered food during meal service.Observations of the walk in and reach in refrigerators revealed the following:A pan was covered in clear plastic wrap and labeled scrambled eggs and ham and 7/17 written in black marker but did not specify if it was a production date or use by date.A pan that contained sliced ham was covered with clear plastic wrap and did not have any kind of label or date.Two separate pans that contained an unidentified food item and were covered with clear plastic wrap and did not have any kind of label or date.Two ten pound packages of ground beef and one 40 pound box of chicken were in the walk-in refrigerator with no use or freeze by date. A pan of cooked eggs was covered with clear plastic and written on the plastic in black marker 7/10 but did not specify if it was a production date or use by date.A pan of liquid egg bake liquid was covered with plastic and written on the plastic in black marker was 7/16 but did not specify if it was a production date or use by date.Observations in dry food storage revealed the following:Multiple pieces of food and debris were on the floor and under shelving including 30 to 40 pieces of multi colored cereal, small dried pieces of cardboard, onion peels, dirt, approximately 20 individual packets of soy sauce, three condiment packets of a sauce or dressing, five packets of individual sweetener, two disposable gloves, two styrofoam cups and plastic lids.Two cases of potato chips in bags were on the floor.Three black tubs on a shelf contained portion control plastic lids and cups with visible crumbs and debris inside the tubs Some lids and cups were out of their sleeves and on top of the crumbs in the tub. IV. Staff interviewsThe dietary manager (DM) and cook #1 were interviewed on 7/22/26 at 1:15 p.m. The DM said if something in the kitchen could not be reached to clean it, then maintenance would clean the item The DM said he cleaned the light after the dust was pointed out, but did not notice the dust prior to the survey. The DM said there was a cleaning schedule in use for the kitchen and it was designed to have daily, weekly and monthly cleaning tasks. He said he was making changes to the cleaning schedule. He said some of the dents in the walls were there prior to him working in the building. He said the dish room FRP door panels were removed to get the new dish machine in the dish room and the vendor was supposed to put the FRP back on the door frame but never did. The DM said there was enough room in dry storage to store their food off the floor.Cook #1 said the facility had a kitchen cleaning list. [NAME] #1 said when she labeled food, she labeled the item with the date she made the food, and then the use by date. She said the food the staff made in house was kept for three days, but they did not always save their food. She said other items would be kept for seven days. She said she and the other cook always label and date their food. The DM said he was going to talk to the staff (after the survey) about using dissolvable food labels if the staff preferred those to label their food items. He said the label should include the name and expiration date of the item. He said most items were dated with expiration dates seven days out.

Based on observations and interviews, the facility failed to ensure residents consistently received food prepared by methods that conserved nutritive value and was palatable in taste, texture and temperature.Specifically, the facility failed to ensure the residents' food was palatable in temperature appearance.Findings include: I. Facility policy and procedureThe Food Preparations Guidelines policy, April 2025, was provided by regional clinical resource #2 on 7/23/26 at 10:49 a.m. It read in pertinent part, It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status. The cook, or designee, shall prepare menu items following the facility's written menus and standardized recipes. Food shall be prepared by methods that conserve nutritive value, flavor and appearance. This includes, but is not limited to: Storing food in a manner to minimize exposure to light and air; preparing foods as directed; cooking foods in appropriate amounts of water (avoid large volumes); minimizing holding time prior to meal service; and, food and drinks shall be palatable, attractive, and at a safe and appetizing temperature. Strategies to ensure resident satisfaction include: Providing meals that are varied in color and texture; using spices or herbs to season food in accordance with recipes; serving hot foods/drinks hot and cold foods/drinks cold; addressing resident complaints about foods/drinks; honoring resident preferences, as possible, regarding foods and drinks; and, staff shall offer residents appropriate alternatives when they choose not to consume food/drink that is initially served or when a different food/drink choice is requested.II. Resident interviewsResident #70 was interviewed on 7/20/26 at 9:20 a.m. Resident #70 said breakfast was cold. He said he ate in his room. He said lunch and supper were also often served cold, but breakfast was consistently served cold. He said he did not ask the staff to warm up his food because the staff were too busy.Resident #72 was interviewed on 7/20/26 at 2:41 p.m. Resident #72 said she ate in her room. She said the food was not consistently hot or cold as it should have been. She said she got her food too late and it was cold. She said the hot dogs were never hot and always cold so she asked the certified nurse aides (CNA) to warm up her food.Resident #49 was interviewed on 7/20/26 at 4:25 p.m. Resident #49 said the food was not good.Resident #11 was interviewed on 7/20/26 at 9:40 a.m. Resident #11 said he ate primarily breakfast and lunch. He said the food was served cold. He said the food was bland. III. Test trayOn 7/22/26 at 12:30 p.m., a test tray for a regular diet, that was served at the same time as resident room trays, was evaluated by three surveyors during the lunch meal service. The test tray was plated in the kitchen at 12:10 p.m., arrived on the unit at 12:11 p.m. and was tested for temperature and tasted immediately after the last resident on the unit was served their meal.The test tray served consisted of chicken paprikash, [NAME] pasta, steamed broccoli florets, a dinner roll and a slice of cream pie. The temperatures of the chicken paprikash, [NAME] pasta and steamed broccoli florets were taken immediately upon receipt of the test tray. The [NAME] pasta and steamed broccoli florets were served too cold. The cream pie did not hold its shape and was the texture of soft pudding.The temperature of the steamed broccoli on the test tray was 110 degrees fahrenheit (F) .The temperature of the penne pasta on the test tray was 118 degrees F.IV. Staff interviewsThe dietary manager (DM) and cook #1 were interviewed on 7/22/26 at 1:15 p.m. The DM said he did not have complaints from residents in the food committee meetings so did not know cold food was a concern. He said the plate warmer for the hot pellets (for keeping room trays plate hot) had been broken for about a year. He said the operations manager would regularly get a test tray but he was unsure if the operations manager took the temperature of the food on the test tray. The DM said the staff used a pudding mix to make the cream pie but needed to adjust the recipe in the future to use less milk so the pie would hold its shape and not be as soft.Cook #1 said the staff did not take food temperatures at the end of the meal, but she stirred her food during the meal and tried to keep it covered so the food would stay hot. [NAME] #1 said if the hot pellet warmer was fixed maybe the food would be hotter.The operations manager was interviewed on 7/23/26 at 12:30 p.m. The operations manager said he did get test trays from the kitchen, but did not take temperatures of the food on the test trays. He said he did not know the warmer for the hot pellets was broken.

Based on record review and interviews, the facility failed to ensure residents who required dialysis services received such services consistent with professional standards of practice for one resident (#8) reviewed for dialysis out of 42 sample residents. Specifically, the facility failed to consistently and thoroughly complete the dialysis communication forms for Resident #8.Findings include:I. Facility policy and procedureThe Hemodialysis policy, reviewed 5/5/25, was provided by regional clinical resource #1 on 7/24/26 at 11:10 a.m. It read in pertinent part, The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include the ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to:Timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility;Physician/treatment orders, laboratory values, and vital signs. The nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding or other complications.II. Resident #8A. Resident statusResident #8, age greater than 65, was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included chronic kidney disease stage 4, end stage renal disease and type 2 diabetes mellitus with diabetic chronic kidney disease.The 6/18/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of eight out of 15. The resident required setup or clean-up assistance for toileting, bathing, and personal hygiene.The MDS assessment indicated the resident received dialysis treatment.B. Record reviewReview of Resident #8's dialysis care plan, initiated 6/9/26, revealed the resident had begun dialysis services for renal failure. Interventions included collaborating with dialysis with any change of condition with resident, not drawing blood or taking blood pressure in arm with graft, encouraging resident to go for the scheduled dialysis appointments, and monitoring/documenting/reporting as needed (PRN) any signs/symptoms of infection to access site: redness, swelling, warmth or drainage.Review of Resident #8's July 2026 CPO revealed the following physician's orders related to dialysis:Dialysis on Tuesday/Thursday/Saturday, arrival time 10:10 a.m. and 10:30 a.m. appointment time. The resident would be done at 2:30 p.m. and picked up at 2:50 p.m., ordered 6/9/26. Fill out the dialysis communication sheet and ensure the resident has a sack lunch from the kitchen and ready to go by 9:30 a.m., ordered 6/9/26.Resident #8's dialysis communication forms were retrieved from the resident medical record (EMR). Each communication form had three sections on one sheet of paper, which revealed the following: The first section of the communication form was to be filled in by the facility before dialysis with the resident's name, date of birth , room number, and the resident's vital signs, which included blood pressure, pulse, respirations, temperature, and pain. The section indicated to document the physician's name, the resident's shunt/catheter location/status, and medications administered prior to dialysis. The section also prompted the nurses to document meal/snack sent and additional information such as changes in condition, physician order changes, and new labs since last visit. A facility nurse's signature, date and time were required to validate that the information was completed.The second section of the communication form was to be filled in by the dialysis center staff with the resident's vital signs, the resident's weight pre- and post-dialysis, the dialysis start time and end time, and the fluid removed. The section indicated to document the resident's shunt/catheter location/status, meal/snack intake and any additional information such as changes in condition, medications administered, labs drawn and lab results; and if there were any new orders/recommendations. A dialysis nurse's signature, date and time were required to validate that the information was completed.The third section of the communication form was to be filled in by the facility after dialysis with the resident's vital signs and shunt/catheter location/status. The section indicated to document the general condition of the resident, the catheter dressing, and if any bleeding. A facility nurse's signature, date and time were required to validate that the information was completed. Review of Resident #8's dialysis communication forms revealed the following:The pre-dialysis section had the vital signs were left blank on 6/20/26.The post-dialysis section was not filled out in its entirety on 6/16/26 and 6/20/26.The post-dialysis section had the vital signs left blank on 6/11/26, 6/23/26, 6/25/26 and 7/2/26.III. Staff interviewsCertified nurse aide (CNA) #6 was interviewed on 7/22/26 at 4:15 p.m. CNA #6 said she assisted Resident #8 with bathing and toileting in the morning before Resident #8 left for the dialysis center. CNA #6 said nursing staff obtained the resident's vital signs and documented them on the communication forms. CNA #6 said Resident #8 was independent and able to take care of herself upon returning from the dialysis.Registered nurse (RN) #4 was interviewed on 7/22/26 at 3:52 p.m. RN #4 said the nursing staff obtained Resident #8's vital signs and documented them on the communication form before she left for the dialysis center. RN #4 said the facility did not take Resident #8's weight before dialysis avoiding incorrect measurement. RN #4 said the dialysis center would obtain Resident #8's pre- and post-dialysis weights for accuracy. RN #4 said nursing staff assessed Resident #8's dialysis access site and obtained vital signs upon her return to the facility. RN #4 said they were not required to document post-dialysis vital signs on the communication form. RN #4 said she was unsure why the post-dialysis section was not completed on some dialysis communication forms. The assistant director of nursing (ADON) and the director of nursing (DON) were interviewed together on 7/22/26 at 4:29 p.m. The ADON said the staff informed Resident #8 about her scheduled dialysis treatment appointments. The ADON said nursing staff obtained vital signs, documented the dialysis communication form and sent it with the resident. The ADON said a CNA accompanied Resident #8 to the dialysis center.The DON said the pre- and post-dialysis weights were taken at the dialysis center. The DON said nurses checked Resident #8's vital signs and the dialysis site upon her return to the facility. Nurses would notify the physician if there were any changes. The DON said nurse filled out the dialysis communication form and passed it to the medical records department to be uploaded to Resident #8's EMR. The DON confirmed there were some incomplete dialysis communication forms in Resident #8's EMR. The DON said she would provide education to the nurses regarding accurate completion of the communication forms.

Based on observations, record review and interviews, the facility failed to ensure respiratory care was provided in accordance with professional standards for two (#13 and #76) of nine residents out of 42 sample residents.Specifically, the facility failed to:-Ensure Resident #13 have an active order for oxygen therapy; and,-Follow oxygen administration order for Resident #76. Findings include: I. Facility policy and procedure The Oxygen Administration policy, implemented 4/11/25, was provided by regional clinical resource #1 on 7/24/26 at 11:10 a.m. It read in pertinent part, Oxygen is administered to residents who need it, consistent with professional standard of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. Personnel authorized to initiate oxygen therapy include physicians, registered nurses (RNs), licensed practical nurses (LPNs), and respiratory therapists. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to the type of oxygen delivery system, when to administer, such as continuous or intermittent and/or when to discontinue, and equipment setting for the prescribed flow rates. II. Resident #13 A. Resident status Resident #13, age less than 65, was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure, obstructive sleep apnea and heart failure. The 5/26/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The MDS assessment did not indicate Resident #13 was receiving oxygen therapy. B. Observations On 7/20/26 at 4:35 p.m. Resident #13 was lying on her bed in her room with her nasal cannula connected to an oxygen concentrator set at 5 liters per minute (LPM). The resident had her oxygen on. On 7/21/26 at 4:03 p.m. Resident #13 was lying on her bed without the oxygen on. An unidentified nurse entered Resident #13's room to pass medication. Resident #13 asked the nurse to be connected to the oxygen. The unidentified nurse turned on the oxygen concentrator and assisted Resident #13 to wear her nasal cannula which was connected to an oxygen concentrator set at 5 LPM. -However, Resident #13's physician's order for oxygen was discontinued on 5/28/26 (see record review below). C. Resident interview Resident #13 was interviewed on 7/21/26 at 4:03 p.m. Resident #13 said the physician mentioned the oxygen flow rate should be at 4 LPM. Resident #13 said she had been using oxygen during the daytime for a while. She said she used the oxygen connected to the continuous positive airway pressure (CPAP) machine at night. Resident #13 said no one had informed her to discontinue using oxygen during the day. D. Record review Review of Resident #13's July 2026 CPO revealed the following physician's orders: Oxygen 4 liters per nasal cannula every night at bedtime and as needed (PRN) during naps for sleep apnea (until CPAP was delivered) to be discontinued on 5/15/26, ordered 5/8/26. -However, observations revealed Resident #13 was receiving oxygen during the daytime at a flow rate set at 5 LPM (see observations above). The respiratory care plan, revised 5/26/26, documented Resident #13 had a potential impaired gas exchange related to shortness of breath, sleep apnea and acute respiratory distress (ARD). Resident #13 required 4 liters of oxygen per nasal cannula and CPAP at overnight shift. Interventions included implementing measures to improve respiratory status: elevate head of bed, oxygen per order and calm environment. -However, the oxygen therapy order for Resident #13 at daytime was discontinued on 5/8/26 (see interviews below). E. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 7/23/26 at 9:17 a.m. CNA #5 said nurses let him know each resident's prescribed oxygen flow rate. He said he had to check the oxygen concentrator to ensure it was set at the appropriate flow rate. CNA #5 said he had to ensure residents had a filled portable oxygen tank when they were out of their room. CNA #5 said Resident #13 used oxygen while in bed during both the daytime and at night. CNA #5 said he was not sure of Resident #13's prescribed oxygen flow rate. CNA #5 said he was not aware Resident #13's daytime oxygen order was discontinued. Licensed practical nurse (LPN) #1 was interviewed on 7/23/26 at 11:05 a.m. LPN #1 the physician was responsible for ordering oxygen therapy. LPN #1 said a nurse could initiate the oxygen order in case of emergency, the physician would finalize the order. LPN #4 said the oxygen therapy order specified the prescribed flow rate and whether the oxygen should be administered as needed or continuously. LPN #1 said Resident #13 was to receive oxygen only while in bed. LPN #1 said Resident #13 used nasal cannula for oxygen during the day and CPAP at night. LPN #13 said she was not able to locate an active oxygen therapy order in Resident #13's electronic medical record (EMR). The assistant director of nursing (ADON) was interviewed on 7/23/26 at 11:14 a.m. The ADON said Resident #13's daytime oxygen therapy was discontinued on 5/8/26 as Resident #13 was supposed to start using a CPAP with oxygen at night. III. Resident #76 A. Resident status Resident #76, age greater than 87, was admitted on [DATE]. According to the July 2026 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), emphysema, chronic respiratory failure with hypoxia, and hypoxemia. The 6/2/26 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The resident required set up assistance with eating, supervision with oral hygiene, maximal assistance with toileting. She depended on others with showering and dressing. The MDS assessment indicated Resident #76 was receiving oxygen therapy. B. Resident interview and observations Resident #76 was interviewed on 7/20/26 at 10:42 a.m. Resident #76 lying on her bed and she was wearing a nasal cannula in her mouth. There was an oxygen concentrator at the end of her bed. She was receiving 3LPM via nasal cannula. Resident #76 said that she received 3 LPM oxygen therapy via nasal cannula. She said she used the nasal cannula in her mouth otherwise she would get a nosebleed. She said the nosebleed took a long time to stop and she was not on blood thinner. She said her respiratory order has not changed recently. On 7/20/26 at 10:42 a.m. Resident #76 was lying in her bed. The resident had an oxygen concentrator next to her bed. She was receiving oxygen through a nasal cannula that was placed in her mouth. The oxygen concentrator was set to 3 LPM. On 7/21/26 at 9:58 a.m. Resident #76 was lying in her bed. The resident had an oxygen concentrator next to her bed. She was receiving oxygen through a nasal cannula that was placed in her mouth. The oxygen concentrator was set to 3 LPM. At 12:18 p.m. Resident #76 was lying in her bed and eating lunch. The resident had an oxygen concentrator next to her bed. The nasal cannula was placed on her chest. The oxygen concentrator was set to 3 LPM. On 7/21/26 at 3:51 p.m Resident #76 was lying in her bed. The resident had an oxygen concentrator next to her bed. She was not wearing the nasal cannula. The oxygen concentrator was set to 3 LPM. On 7/22/26 at 8:28 a.m. Resident #76 was lying in her bed. The resident had an oxygen concentrator next to her bed. She was receiving oxygen through a nasal cannula that was placed in her mouth. The oxygen concentrator was set to 3 LPM. At 9:49 a.m. CNA #2 checked the oxygen concentrator and verified that the oxygen setting was set to 3 LPM. She said there was no humidifier attached to the respirator. At 10:11 a.m. Resident #76 was lying in her bed. The resident had an oxygen concentrator next to her bed. She was receiving oxygen through a nasal cannula that was placed in her mouth. The oxygen concentrator was set to 3 LPM. -However, Resident #76`s physician's order indicated the oxygen flow rate was supposed to be 5 LPM (see record review below). C. Record review Review of the July 2026 CPO revealed the following physician's orders: -Oxygen therapy at 5 LPM per nasal cannula when in bed, ordered on 5/15/24. -However, observations revealed Resident #76's oxygen was not administered per physician orders (see observations above). The oxygen care plan, revised 7/13/23, revealed the resident had oxygen therapy related to diagnoses of COPD, emphysema, and respiratory failure. Pertinent intervention included administering oxygen via nasal prongs at 5 LPM, humidified. Review of the July 2026 (7/20/26 to 7/23/26) medication administration record (MAR) revealed nursing staff were documenting and signing off that Resident #76 was receiving oxygen at 5 LPM. -However, observations revealed Resident #76's oxygen concentrator was set to 5 LPM (see observations above). D. Staff interviews CNA #2 was interviewed on 7/22/26 at 9:49 a.m. CNA #2 said respiratory company visited monthly to ensure the oxygen concentrator works correctly. CNA #2 said she could adjust the oxygen concentrator setting if needed. She said she checked the respiratory setting on the oxygen concentrator during bed time. She said the daily vital signs were taken by the nurse. She said Resident #76`s oxygen order was 2 LPM. She said she would ask the nurse for the oxygen order if she was unsure about each resident`s order. She said if the residents reported shortness of breath, she would ask the nurse or look up the order in their charts. RN #2 was interviewed on 7/22/26 at 10:31 a.m. RN#2 said that the nurses followed the physician`s order for oxygen therapy. RN #2 said the residents on the 400 Hall were not known to adjust their own oxygen concentrator setting. He said he checked the oxygen concentrator setting in the morning. He said the staff did not document the oxygen concentrator setting and that was the facility`s policy. He said Resident #76`s oxygen order was 5 LPM and continuous. He said Resident #76`s oxygen setting was on 3 LPM and it should have been 5 LPM. The DON was interviewed on 7/23/26 at 1.30 p.m. The DON said the nurse on each shift monitored the oxygen concentrator setting daily. She said the nurse should look at each resident`s oxygen order and verify the correct setting. She said the CNAs could not adjust the oxygen concentrator setting. She said the staff should follow the physician`s order to make sure that the residents receive the correct oxygen flow. She said if the CNA noticed that the concentrator setting was incorrect, they should notify the nurse. She said the respiratory services visited the facility monthly to make sure that the oxygen concentrators worked properly. She said following the physician`s oxygen order was vital for organs to function properly. She said if Resident #76`s physician order indicated a humidifier, then it should be attached to Resident #76`s concentrator.

Based on observations, record review and interviews, the facility failed to ensure one (#79) of two residents reviewed for accidents out of 42 sample residents received adequate supervision to decrease and/or prevent risk for accident hazards.Specifically, the facility failed to ensure Resident #79 was supervised while smoking and kept the smoking material in his room.Findings include:I. Facility policy and procedureThe Resident Smoking policy, implemented 4/11/25, was provided by regional clinical resource #1 on 7/24/26 at 11:10 a.m. It read in pertinent part, It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and nonsmoking residents. Residents who smoke will be further assessed, using the Smoking Safety Screen, to determine whether or not supervision is required for smoking. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan. If a resident or family does not abide by the smoking policy or care plan (e.g. smoking materials are provided directly to the resident, smoking in non-smoking areas, does not wear protective gear), the plan of care may be revised to include additional safety measures. Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff.II. Resident #79A. Resident statusResident #79, age [AGE], was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included tobacco use, hypertension, and acute respiratory failure with hypoxia (not enough oxygen in the blood).The 1/30/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The resident was independent on activities of daily living (ADLs).The MDS assessment indicated the resident used a wheelchair for mobility.B. ObservationsOn 7/21/26 at 12:09 p.m. Resident #79 exited his room holding a cigarette. Resident #79 self-propelled backward in his wheelchair down the hallway. Resident #79 went outside to the designated smoking area and began smoking with other residents. No staff member was present to supervise the residents while they were smoking.C. Resident interviewResident #79 was interviewed on 7/21/26 at 3:50 p.m. Resident #79 said he was an independent smoker and did not require supervision while smoking. Resident #79 said he kept his smoking materials in his room. Resident #79 said he had never burned himself or had burned holes in his clothes. Resident #79 said he sometimes shared cigarettes with other residents. Resident #79 said he did not have a scheduled smoking time and he could smoke whenever he wanted.Resident #79 showed a black lockbox located in the bottom drawer of his nightstand. Resident #79 said he kept his smoking materials inside the lockbox.-However, the 4/27/26 smoking assessment indicated Resident #79 was a supervised smoker and all smoking materials should be kept at the nurse's station (see record review below).D. Record reviewResident #79's smoking care plan, initiated 1/24/25 and revised 7/6/26, documented the resident was at risk for injury and complications related to smoking. Resident #79 was a supervised smoker. Interventions included staff should intervene immediately as needed for safety and notify administrative staff so appropriate follow up actions could be taken if unsafe smoking practices were observed or if it was suspected that resident had violated the smoking policy. Other interventions included educating and informing the resident of the facility smoking policy, including the designated smoking area, and performing smoking assessment on a quarterly basis and as needed to assess for ongoing safety while smoking.The 4/27/26 smoking evaluation documented the resident safely lit smoking materials, held smoking materials safely and disposed of smoking materials appropriately. The evaluation also documented Resident #79 had smoking privilege status safe to smoke with supervision and all smoking material secured at nursing station.-However, Resident #79 smoked without supervision and kept his smoking material in his room (see observation and resident interview above).E. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 7/23/26 at 11:30 a.m. LPN #1 said she completed a smoking assessment upon a resident's admission to the facility. LPN #1 said she documented the assessment in the resident's electronic medical record (EMR). LPN #1 said Resident #79 was determined to be a supervised smoker per assessment, but Resident #79 was not compliant with the facility smoking policy most of the time. LPN #1 said there was a smoking supervision schedule. LPN #1 said the assigned smoking supervisor was expected to be with residents while they were smoking. LPN #1 said she was not sure how Resident #79 kept the smoking material in his room, as those materials were supposed to be kept at the nurse's station.The assistant director of nursing (ADON) was interviewed on 7/23/26 at 11:18 a.m. The ADON said nurses completed smoking assessments for residents and documented them in EMR. The ADON said a smoking supervision included assisting residents who used wheelchairs to get to the designated smoking area, lighting their cigarettes and keeping the smoking materials at the nurse's station. The ADON said another smoking assessment for Resident #79 was completed during the survey and determined him as a supervised smoker, but it was not uploaded yet to Resident #79's EMR. -However, Resident #79 had previously been assessed to be a supervised smoker on 4/27/26 (see record review above).

Based on record review and interviews, the facility failed to maintain accurate medical records for advance directives on each resident for two (#40 and #101) of eight residents reviewed out of 42 sample residents. Specially, the facility failed to ensure Resident #40 and Resident #101's medical orders for scope of treatment (MOST) form corresponded with the computerized physician orders (CPO) for cardiopulmonary resuscitation (CPR).Findings include:I. Resident #40 A. Resident statusResident #40, age less than 65, was admitted [DATE]. According to the [DATE] computerized physician orders (CPO), the diagnoses included Lennox-Gastaut syndrome (severe form of epilepsy), protein calorie malnutrition, and chronic obstructive pulmonary disease (COPD).The [DATE] minimum data set (MDS) assessment documented the resident had a memory problem and was moderately impaired to make decisions regarding daily life per staff assessment. The resident needed set-up or clean-up assistance with activities of daily living.B. Record reviewA review of Resident #40's [DATE] CPO revealed a physician's order for advanced directive that Resident #40's code status was full code, ordered [DATE].On [DATE] at 4:00 p.m. Resident #40's MOST form was reviewed. Resident #40's MOST form revealed the resident's representative signed the MOST form on [DATE] and the physician's assistant (PA) signed the MOST form on [DATE]. The MOST form indicated no CPR with selective treatment which included intravenous (IV) antibiotics and fluids, do not intubate and to avoid intensive care. -However, the physician's order failed to match the resident's MOST form.II. Resident #101 A. Resident statusResident #101, age less than 65, was admitted [DATE]. According to the [DATE] CPO, the diagnoses included cirrhosis (late stage scarring) of the liver, anxiety and depression.Resident #101's [DATE] brief interview for mental status (BIMS )assessment documented the resident was severely cognitively impaired with a score of five out of 15. Resident #101's ADL care plan documented she required assistance with all activities of daily living (ADL).B. Record reviewA review of Resident #101's [DATE] CPO revealed a physician's order for advanced directive that Resident #101's code status was full code, ordered [DATE].On [DATE] at 4:15 p.m. Resident #101's MOST form was reviewed. The MOST documented the resident's representative signed the form on [DATE] and the PA signed the form on [DATE]. The MOST form indicated no CPR, comfort treatment, and no artificial treatment by tube.-However, the physician's order failed to match the resident's MOST form.Resident #101's hospice care plan, revised [DATE] documented the resident had a terminal prognosis and was on hospice comfort care related to a diagnosis of cirrhosis of the liver.III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on [DATE] at 4:05 p.m. LPN #1 said the facility made copies of the MOST forms to provide emergency staff if a resident was sent out to the emergency department. LPN #1 said she updated Resident #40's MOST form when she returned from the hospital and would update the Resident #40's physician order so it matched the MOST form.The director of nursing (DON) was interviewed on [DATE] at 12:32 p.m. The DON said the facility provided education to the staff (during the survey) about advanced directives. The DON said previously that a resident with an order for no CPR remained a full code until the resident's MOST form was signed by a physician. The DON said the staff were educated (during the survey) that the staff can honor the resident's advanced directive wishes right away even if the physician had not yet signed the MOST form.IV. Facility follow upA review of Resident #101's and Resident #40's [DATE] CPO on [DATE] (during the survey) revealed a physician's order for advanced directive that Resident #101's and Resident #40's code status was changed to no CPR to match the residents MOST forms.On [DATE] at 3:45 p.m. the regional clinical resource #1 provided an action plan with staff education for advanced directives. The action plan and education documented the facility failed to ensure that the advanced directive order in the resident's electronic medical record (EMR) matched the resident's MOST form. The systemic changes documented that beginning on [DATE] staff were educated on the process of obtaining the residents' MOST form and ensuring the physician's order matched the resident's MOST form.The education documented it was the expectation that nursing completed a MOST form with the resident and/or resident representative upon admission to the facility. An order should then be put into the residents EMR under advanced directives upon resident/representative signature. MOST forms should also be reviewed with the resident/representative during care conferences and after return from the hospital. The advanced directive order in the resident's EMR should always match what was on the resident's MOST form. The education was provided by the regional clinical resource #1 to the nursing staff.

Based on record review and interviews, the facility failed to ensure residents were kept free from physical abuse for two (#11 and #7) of eight residents reviewed for abuse out of 11 sample residents.Specifically, the facility failed to: -Protect Resident #7 from physical abuse by Resident #9; and,-Protect Resident #11 from physical abuse by Resident #10.Findings include:I. Facility policy and procedureThe Abuse, Neglect, and Exploitation policy, dated 4/11/25, was provided by the nursing home administrator (NHA) on 2/25/26 at 2:41 p.m. It read in pertinent part, It is the policy of this facility to protect the health of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. The facility will develop and implement written policies and procedures that:-Prohibit and prevent abuse of residents;-Establish policies and procedures to investigate abuse allegations; and,-Include training for staff on activities that constitute abuse and abuse prevention. Prospective residents will be screened to determine whether the facility has the capability and capacity to provide necessary care and services for each resident admitted to the facility:-An assessment of the individual's functional and mood/behavioral status, medical acuity, and special needs will be reviewed prior to admission; and,-The facility will make individual determinations in consideration of current staffing patterns, staff qualifications, competency and knowledge, and clinical resources, and physical environment. The facility will implement policies and procedures to prevent and prohibit all types of abuse by: -Identifying, correcting, and intervening in situations in which abuse is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and ensuring that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms;-The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect;-Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur; and-Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors.II. Incident of physical abuse of Resident #7 by Resident #9 on 2/7/26A. Facility investigationThe 2/7/26 facility investigation revealed that an altercation occurred between Resident #7 and Resident #9 in the dining room. The investigation revealed the altercation was witnessed and reported by another resident. The investigation documented that the witness told staff that she witnessed Resident #9 hit Resident #7 on the chest and on the shoulder. The investigation revealed staff immediately separated Resident #7 and Resident #9 and placed Resicent #9 on a one-on-one for constant supervision for the safety of all residents.The investigation revealed Resident #7 had expressive aphasia, which severely limited her ability to speak and prevented her from verbally reporting the incident to staff. The investigation revealed Resident #7 had a behavior of agitating other residents by pointing and muttering. Resident #9 had a history of behavioral outbursts during psychotic episodes. The investigation revealed Resident #9 told staff she did not recall the altercation with Resident #7.The investigation substantiated the incident of physical abuse. B. Resident #7 (victim) 1. Resident statusResident #7, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included schizoaffective disorder (a mental health condition) and depression.The 2/4/25 minimum data set (MDS) assessment revealed Resident #7 had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. Resident #7 required supervision or touching assistance from staff for bed mobility, transfers, dressing, and walking.The assessment revealed Resident #7 had verbal behavioral symptoms toward others for one to three days during the assessment look-back period.2. Record review The mood and behavior care plan, initiated 11/27/24, revealed Resident #7 had been an aggressor and recipient of physical aggression. Pertinent interventions included administering medications as ordered (initiated 3/1/25), separating the resident from Resident #9 (initiated 2/9/26), and monitoring Resident #7 closely while in the dining room during meal times and activities (initiated 2/13/26).The 2/7/26 nurse progress note revealed the nurse heard a resident say Resident #7 had been hit several times in the chest and on the shoulder by Resident #9. The progress note revealed that Resident #7 was unable to verbalize what occurred. The nurse documented that she completed an assessment of Resident #7 and no injuries were present. The 2/9/26 interdisciplinary team (IDT) progress note revealed that the cause of the altercation between Resident #7 and Resident #9 was that Resident #7 was impulsive, that she had finished her activity in the dining room and was waiting for her dinner. The IDT progress note revealed the IDT recommended that a nurse be close to the dining room during meal times and activities. C. Resident #9 (assailant) 1. Resident statusResident #9, age less than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included stroke, left-sided paralysis, bipolar disorder (a mental health condition), depression, and anxiety. The 2/3/26 MDS assessment revealed Resident #9 had moderate cognitive impairment with a BIMS score of 10 out of 15. Resident #9 was independent with bed mobility, required supervision or touching assistance from staff for transfers, was non-ambulatory and used a manual wheelchair independently after being set up by staff. The assessment indicated Resident #9 had no physical or verbal behaviors directed at others during the assessment look-back period. 2. Record reviewThe mood and behavioral care plan, initiated 11/5/25, identified that Resident #9 had a history of taking items from staff, swinging at staff, and throwing objects at other residents.Pertinent interventions included administering medications as ordered (initiated 11/5/25), monitoring behavioral events (initiated 11/5/25), and providing care one-on-one to monitor for physical aggression toward other residents (initiated 2/12/26). The 2/7/26 nurse progress note revealed that Resident #9 was involved in an altercation with another resident (Resident #7) in the dining room. The nurse's progress note revealed she completed an assessment on Resident #9 and found no injuries. The nurse's progress note documented Resident #9 told her Resident #7 had scratched her and she did not know why. The progress note revealed Resident #9 was placed on a one-on-one with staff for monitoring and the safety of other residents. The 2/9/26 IDT progress note revealed that the cause of the altercation between Resident #7 and Resident #9 was Resident #9 was impulsive, had a history of aggression towards others, was bipolar, and had a borderline personality disorder with a recent change to medications. The IDT initiated a new safety intervention to place Resident #9 on one-on-one supervision, and recommended a referral to behavioral health services and a physician review of her prescribed medications.III. Incident of physical abuse of Resident #11 by Resident #10 on 2/14/26A. Facility investigationThe 2/14/26 facility investigation revealed that a physical altercation occurred between Resident #10 and Resident #11 while they were on a supervised smoking break. The investigation documented Resident #10 was agitated and objected to Resident #11 placing his legs in proximity to him. The investigation documented Resident #10 stood up from his wheelchair and attempted to swing at Resident #11 and Resident #11 placed his foot against Resident #11's chest to create distance from Resident #10. The investigation documented Resident #10 responded by pulling himself closer, grabbing Resident #11 by the shirt and punching Resident #11 in the face near his right eye. The investigation documented the staff member supervising the smoke break intervened and separated the two residents immediately. The investigation documented Resident #10 and Resident #11 were assisted to their rooms and assessed by the nurse. The investigation revealed the facility implemented a new safety protocol and required two staff members to supervise the smoking area when five or more resident smokers were present. Staff were educated to ensure Resident #10 and Resident #11 were kept separate from each other in the facility and while on smoking breaks. Additionally, staff were educated to intervene if there was an escalation of behaviors between Resident #10 and Resident #11.The facility investigation revealed Resident #11 had a history of physical and verbal aggression towards others, was known to be impulsive and had a tendency to engage in confrontations with residents and staff. Resident #10 had a history of physical aggression towards other residents and being combative with staff. Resident #10 was monitored by staff for impulsive behaviors.The investigation revealed after the altercation on 2/14/26, Resident #10 was placed on one-on-one supervision for close supervision to prevent physical aggression toward other residents. The investigation documented Resident #11 told staff that Resident #10 hit him and pointed to his right eye. The investigation documented Resident #10 told staff he did what he needed to do when Resident #11's legs were touching him. The investigation substantiated the incident of physical abuse. B. Resident #11 (victim)1. Resident statusResident #11, age greater than 65, was admitted on [DATE]. According to the October 2025 CPO, diagnoses included a history of traumatic brain injury, depression, anxiety, Parkinson's disease, dementia and schizophrenia (a mental health condition). The 12/18/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of six out of 15. Resident #11 required supervision or touching assistance for bed mobility, transfers, toileting, and walking. Resident #11 used a manual wheelchair and required set-up assistance from staff. The assessment documented Resident #11 had verbal behaviors directed at others for one to three days during the assessment look-back period.2. Record reviewThe verbal aggression care plan, initiated 11/16/17, revealed Resident #11 was verbally aggressive at times due to dementia, depression and anxiety. The care plan identified triggers for verbal aggression, which were from others staring at him and having to wait for his cigarettes on smoking breaks.The cognitive communication care plan, initiated 8/7/2020, revealed Resident #11 had difficulty understanding others due to his history of traumatic brain injury, dementia and schizophrenia. Pertinent interventions included monitoring Resident #11 for his position in groups to promote communication with others and providing adequate time for the resident to respond to others.The 2/14/26 nurse progress note revealed Resident #11 was the recipient of physical aggression by Resident #10 in the smoking area. The nurse completed an assessment and found a 0.5 centimeter (cm) by 0.5 cm red area on the right side of his face and redness on the right cheek and right jaw. The progress note revealed Resident #11 denied pain from the altercation. The progress note revealed Resident #11 did not know what happened and reported to the nurse that Resident #10 just kept hitting him. The 2/15/26 IDT progress note revealed the cause of the altercation between Resident #11 and Resident #10 was due to a misunderstanding of personal space. The IDT initiated new interventions to require a second staff member to supervise smoking breaks if the smoking group exceeded five residents. C. Resident #10 (assailant)1. Resident statusResident #10, age greater than 65, was admitted on [DATE] and transferred to another facility on 2/23/26. According to the February 2026 CPO, diagnoses included mood disorder, depression, anxiety and personality disorder.The 12/2/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The assessment revealed Resident #10 required set-up assistance from staff for bed mobility and standing, and supervision from staff for bed mobility and transfers. Resident #10 was independent with using a manual wheelchair. The assessment documented Resident #10 had no physical or verbal behaviors towards others during the assessment look-back period. 2. Record reviewThe anxiety care plan, initiated 4/21/15, revealed Resident #10 had anxiety with verbal aggression towards others. Pertinent interventions included reviewing quarterly for possible dose reduction of medications (initiated 1/3/16) and offering diversion activities when aggressive behaviors were present (initiated 9/28/17).The physical aggression care plan, initiated 2/10/25, revealed Resident #10 had a history of physical aggression towards other residents. Pertinent interventions included administering medications as ordered, anticipating and meeting resident needs, assisting with coping and interacting skills, providing opportunities for positive interactions with staff and residents, explaining all procedures, and discussing unacceptable behavior, monitoring behavior episodes, intervening to protect other residents (initiated 2/10/25) and monitoring one-to-one for physical aggression (initiated 2/16/26).The 2/14/26 at 1:30 p.m. nurse progress note revealed Resident #10 had been in an altercation with Resident #11 outside in the smoking area. A staff member supervising the smoking break observed Resident #10 grab Resident #11 by the shirt and punch him multiple times. The nurses documented Resident #10 told her Resident #11 had swung his leg towards his chest. The progress note revealed the nurse completed an assessment and documented Resident #10 had no injuries from the altercation.The 2/16/26 IDT progress note revealed the cause of the altercation between Resident #11 and Resident #10 was due to a misunderstanding of personal space in close physical proximity to each other. The IDT initiated new interventions and placed Resident #10 on one-to-one monitoring when outside of his room.IV. Staff interviewsThe NHA, the operations director and the director of nursing (DON) were interviewed together on 2/25/26 at 4:45 p.m. The NHA said the altercation between Resident #7 and Resident #9 occurred in the dining room while residents were waiting for their dinner. The operations director said a staff member reported she observed Resident #9 punch Resident #7 on the chest and shoulder. The operations director said after the altercation, staff responded immediately by separating the residents. The operations director said the nurse assessed both residents and neither resident had injuries. The NHA said Resident #9 was placed on one-on-one supervision for prevention of additional altercations. The NHA said resident #9 would remain on one-on-one supervision until the IDT reviewed behaviors and determined that less monitoring was appropriate. The DON said there were no additional altercations between Resident #7 and Resident #9. The DON said Resident #9 had occasional verbal aggression with staff during care that resolved when staff redirected or re-approached Resident #9. The NHA said the altercation between Resident #10 and Resident #11 occurred outside in the smoking area. The operations director said the altercation was observed by a staff member supervising the smoking break and said the altercation occurred quickly, and the staff member was unable to intervene in time to prevent Resident #10 from hitting Resident #11. The operations director said after the altercation, Resident #10 and Resident #11 were separated, assessed by the nurse and had no injuries. The operations director said Resident #10 was placed on one-to-one supervision for resident safety. The operations director said that in response to the altercation, the facility initiated a policy change to require two staff members to monitor smoking breaks when the smoking group exceeded five residents. The NHA said Resident #10 agreed to a referral to another long-term care facility and transferred on 2/26/26. The DON said neither victim, Resident #7 or Resident #11, had injuries or changes to their mood or behaviors after the altercations.

Based on record review and interviews, the facility failed to ensure one (#1) of four residents were kept free from abuse out of six sample residents. Specifically, the facility failed to ensure Resident #1 was kept free from physical abuse by Resident #2 Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, dated 4/11/25, was provided by the nursing home administrator (NHA) on 11/5/25 at 11:22 a.m. It read in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect and exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse.II. Incident of physical abuse towards Resident #1 by Resident #2 on 9/9/25.A. Facility investigationThe 9/9/25 facility investigation was provided by the NHA on 11/4/25 at 12:19 p.m.The investigation, documented at 4:45 p.m., revealed Resident #2 had accused his roommate, Resident #1, of stealing from him and would not allow Resident #1 to enter the room. Resident #2 had blocked the door with his body, called Resident #1 a thief and pushed him. The investigation documented both residents had cognitive impairments. Resident #1 was interviewed by the assistant director of nursing (ADON) and said he did not feel safe when asked if he was safe here. He said Resident #2 had treated him in an upsetting manner. He said Resident #2 had punched and kicked during this interaction and he tried to kick him out of the room the day before. Resident #2 was interviewed by the ADON. Resident #2 said Resident #1 started the fight and they were mad at each other. He said they both had hands on each other. The investigation documented the incident was substantiated. The investigation documented Resident #2 was then moved to a private room, placed on alert charting for the next 72 hours. He was also placed on 15-minute checks. B. Resident #1 (victim)1. Resident statusResident #1, age [AGE], was admitted on [DATE]. According to the November 2025 computerized physician order (CPO) diagnoses included vascular dementia.The 6/17/25 minimum data set (MDS) assessment revealed the resident had moderately impaired cognitive status with a brief interview for mental status (BIMS) score of 12 out of 15. Resident #1 required a walker and supervision to touching assistance for activities of daily living (ADL).The MDS assessment documented the resident did not have verbal or physical behaviors directed at others. C. Resident #2 (assailant)1. Resident statusResident #2, age [AGE], was admitted on [DATE]. According to the November 2025 CPO, diagnoses included unspecified dementia with agitation, restlessness and agitation, altered mental status and communication deficits. The 9/17/25 MDS assessment revealed the resident had severely impaired cognitive status with a BIMS score of five out of 15. He was independent with activities of daily living (ADL).The MDS assessment revealed the resident did not have any behaviors or wandering tendencies. 2. Record reviewThe mood/behavior care plan, initiated 1/22/25 and revised 11/3/25, documented Resident #2 would become physically aggressive when agitated by other residents, he was at risk for increased confusion and frustration with the diagnosis and placement. He had a history of telling other residents to get out of his way and he did not want them there. He verbalized not being happy in the facility and would wander into other resident's rooms. Interventions included redirecting the resident when he became agitated, placing the resident on one-to-one for safety, offering food and drink when he became agitated and 15-minute checks for elopement risk and behaviors.The cognitive care plan, initiated 12/27/24 and revised 3/31/25, documented Resident #2 was at risk of increased confusion and frustration with his diagnosis and placement. Interventions included, offering food or drink, change of environment when he became frustrated and to redirect when he became agitated. The elopement care plan, initiated 1/24/25 and revised 11/3/25, documented Resident #2 was an elopement risk/wanderer related to being disoriented to place, history of attempting to leave the facility unattended with impaired safety awareness. Resident #2 was on 15-minute checks for elopement risk and behaviors. Pertinent interventions included identifying patterns of wandering and completing an elopement/wander risk assessment quarterly and as needed. Review of the electronic medical record (EMR) revealed the resident had been admitted to the secured unit.The progress note, dated 8/13/25, documented Resident #2 became agitated and aggressive towards another resident. He was put on one-to-one observation for behaviors. The 9/9/25 Room Change Notification form indicated Resident #2 was moved to a private room for the health and safety of him and other residents. III. Staff interviewsCertified nurse aide (CNA) #2 was interviewed 11/4/25 at 1:18 p.m. CNA #2 said she got information regarding the residents when she did a walk through of the unit with the staff going off shift. She said she was not aware of where to look for specific information regarding triggers for resident behaviors. She said she asked the nurse if she had questions. CNA #1 was interviewed 11/4/25 at 1:27 p.m. CNA #1 said she worked on Resident #2's unit. He said he was usually worked another hall and was not aware of any specific behavior triggers which would cause Resident #2 to act aggressively. He said the 15-minute checks were to monitor the resident's location because he wandered. CNA #1 said he was not aware of the incident on 9/9/25. The director of nursing (DON) was interviewed 11/5/25 at 10:11 a.m. The DON said when Resident #2 was moved off the secured unit he was placed with a roommate. The DON said the roommate had verbalized concerns with Resident #2, so the interdisciplinary team (IDT) decided to move Resident #2 to another room, with Resident #1, before there were any incidents. The DON said staff could look at the Kardex (staff directive tool) for information about triggers, behaviors and interventions. The DON said that care plans should include resident specific triggers and interventions for mood and behavior. The DON said knowing this information assisted staff on what to look for especially if they were new to the resident. She said if a resident had a change in behavior this is discussed in the morning IDT meeting and the care plans were updated with the new behavior and interventions. The DON said the staff were notified verbally of changes and this information was expected to get passed on from shift to shift. CNA #3 was interviewed 11/5/25 at 11:09 a.m. CNA #3 said she checked on Resident #2 because he punched someone and to monitor his location because he wandered up and down the halls. She said she did not know what triggers Resident #2 to become upset with other residents. She said Resident #2 liked to walk the hallways and sometimes needed redirection to his room because he would get lost.

Based on record review and interviews, the facility failed to ensure one (#2) of six residents investigated for abuse out of seven sample residents were kept free from physical abuse. Specifically, the facility failed to protect Resident #2 from two physical abuse altercations by Resident #3. Findings include: I. Facility policy and procedure The Abuse policy, revised on 6/11/24, was provided by the nursing home administrator (NHA) on 1/30/25 at 2:42 p.m. The policy read in pertinent part, Every resident has the right to be free from abuse. All occurrences of resident abuse shall be promptly reported to the abuse coordinator for investigation. The facility will ensure that all residents are protected during and after abuse investigations by: -Responding immediately to protect the alleged victim; -Increasing supervision of the alleged victim and the other residents as indicated; and, -Providing emotional support to the resident during and after the investigation. Residents with aggressive or abusive behavior shall have their care plans include approaches to reduce or eliminate risk for abuse. II. Incidents of physical abuse towards Resident #2 by Resident #3 A. Facility investigation of the altercation on 1/7/25 The 1/7/25 facility occurrence investigation was provided by the NHA on 1/30/25 at 1:15 p.m. The investigation documented that at 6:51 p.m., certified nurse aide (CNA) #1 heard Resident #3 yelling at Resident #2 to get away from her. The nurse responded immediately and discovered Resident #3 pushed Resident #2 to the floor. The nurse completed assessments on both residents, and no injuries were apparent. Resident #3 was redirected by staff and the residents were separated immediately. The family, the physician and the administration were notified of the occurrence. Resident #2 recalled that she fell , and the investigation documented that neither resident recalled the physical occurrence. Resident #3 was placed on frequent monitoring for behavioral changes and redirection. The facility investigation determined Resident #2 was pushed to the floor by Resident #3 but abuse between the residents was not substantiated. -However, abuse occurred when Resident #3 pushed Resident #2 to the floor. B. Facility investigation of the altercation on 1/14/25 The 1/14/25 facility abuse investigation was provided by the NHA on 1/30/25 at 1:15 p.m. The investigation documented the nurse witnessed Resident #3 approach Resident #2 with agitation and push Resident #2 in her face. The investigation documented that the nurse assessed the residents in the altercation and the residents had no apparent injuries. The investigation documented that the residents were separated and Resident #3 was placed on a permanent one-to-one staff observation for resident safety. On 1/14/25, Resident #3 was transported to the hospital for emergency evaluation and was prescribed a new antipsychotic medication, Olanzapine 5 milligrams (mg) twice daily for agitation/anxiety. The facility investigation determined Resident #2 was pushed in the face by Resident #3 but abuse between the residents was not substantiated. -However, abuse occurred when Resident #3 pushed Resident #2 in the face. II. Resident #3 - assailant A. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the January 2025 computerized physician's orders (CPO), diagnoses included Alzheimer's disease unspecified, dementia with behavioral disturbance, depression, anxiety and unspecified disorientation. Resident #3 resided in the memory care unit of the facility. The 1/21/25 minimum data set (MDS) assessment documented Resident #3 had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. The assessment documented the resident had inattention present continuously. The resident was prescribed antipsychotic and antianxiety medications. Resident #3 had physical and verbal behavioral symptoms directed toward others for one to three days during the assessment period. Resident #3 put others at significant risk for physical injury for one to three days during the assessment period. Resident #3 was independent with bed mobility, transfers, and ambulation. B. Record review The dementia care plan, revised on 6/23/24, identified that Resident #3 had impaired cognitive function related to dementia and Resident #3 did not have good insight into the disease process. Interventions included administering medications as ordered, keeping the resident's routine consistent with a consistent caregiver, presenting one thought at a time and using the resident's preferred name. The cognitive care plan, revised on 12/30/24, identified Resident #3 as having poor safety awareness and being physically aggressive. Interventions included ensuring the resident's safety, changing the resident's environment to promote safety for self and others and ensuring Resident #3 was not aggressive with people. The physical aggression care plan, revised on 1/2/25, identified Resident #3 had the potential to be physically aggressive related to his diagnosis of dementia. Interventions included administering medications as ordered and analyzing and documenting behavior triggers. -The care plan did not identify behavior triggers or effective behavior interventions for Resident #3. The mood and behavior care plan, revised on 1/7/25, revealed Resident #3 had physically aggressive behaviors. Interventions included administering medications as ordered, interacting with the resident in an empathetic and supportive manner, monitoring and documenting each behavioral event and reviewing the resident in the psychotropic review committee to review the resident's medications. The 1/8/25 physician's progress note documented Resident #3 had increased delirium and aggression toward staff in December 2024. On 1/8/25, the physician gave a new medication order for lorazepam 0.5 mg (antianxiety medication) twice daily, for dementia with agitation. The 1/8/25 nurse progress note documented Resident #3 continued to have behaviors on 1/8/24. Resident #3 was yelling in the hallway and refusing to wear her prescribed oxygen. The 1/9/25 nurse progress note documented Resident #3 was very angry and could not be redirected by staff. The nurse documented Resident #3 had a mood change without warning or trigger. III. Resident #2 - victim A. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included dementia with behavioral disturbance, anxiety and depression. The 11/6/24 MDS assessment revealed the resident had severely impaired cognition and never/rarely made decisions per staff assessment. Resident #2 continuously had inattention and disorganized thinking for one to three days during the assessment period. Resident #2 was independent with bed mobility, transfers, and ambulation. B. Record review The behavior care plan, initiated on 8/10/23, identified Resident #2 had behaviors related to her diagnoses. Interventions included administering medications as ordered, monitoring for medication effectiveness and encouraging appropriate expression of feelings and monitoring behavior episodes to determine cause. IV. Staff interviews CNA #1 was interviewed on 2/3/25 at 1:15 p.m. CNA #1 said she was assigned one-to-one duties to provide care to Resident #3. She said Resident #3 sometimes yelled at staff and residents. She said since Resident #3 was on one-to-one supervision, Resident #3 had not had additional physical altercations. She said the resident appeared to be happy during the day and looked forward to speaking to her family on the telephone. CNA #1 said Resident #3 responded well to consistent caregiver routines. Licensed practical nurse (LPN) #1 was interviewed on 2/3/25 at 1:33 p.m. LPN #1 said when residents were agitated or aggressive, the staff were trained to redirect the resident to prevent escalation of behavior. LPN #1 said it was important for staff to know what specific behavior triggers residents had so that individualized care could be provided. LPN #1 said resident care plans, task assignments and shift reports were all used to report to staff what was helpful for each resident. LPN #1 said Resident #3 was impulsive and the staff knew to watch her closely. She said Resident #3 could move quickly and was agitated when other residents were close to her. She said the staff tried to intervene promptly and redirect Resident #3. LPN #1 said Resident #3 had had no behaviors reported since she had new medications prescribed on 1/14/25. The NHA was interviewed on 2/3/25 at 4:05 p.m. The NHA said Resident #3 had dementia with escalating behaviors since December 2024. The NHA said after the 1/7/25 altercation, the staff began to monitor and observe Resident #3 closely. She said on 1/23/25, the resident was evaluated by a behavior health provider who recommended increasing the resident's medications. The NHA said staff provided dementia care during the day for Resident #3, including providing a consistent environment and caregivers and helping the resident use the telephone. The NHA said Resident #3 was recently transitioned to hospice care services and the hospice providers visited with the resident during the week. The NHA said Resident #2 had not been injured during the altercations. She said Resident #2 was monitored after the 1/7/25 fall and had no apparent injury. She said Resident #2 remained active, pleasant and social in the memory care unit.

Based on record review and interviews, the facility failed to permit one (#5) of two residents out of 13 sample residents to return to the facility following a facility-initiated transfer to the hospital. Specifically, the facility failed to: -Ensure a facility-initiated transfer to the hospital included an appropriate discharge location for Resident #5; and, -Reassess Resident #5's status at the time the resident sought to return to the facility after a facility-initiated transfer to the hospital, and did not allow the resident to return to the facility based upon his status at the time of his transfer to the hospital. Findings include: I. Facility policy and procedure The Discharging/Transferring the Resident policy and procedure, revised December 2016, was provided by the nursing home administrator (NHA) on 9/24/24 at 11:48 a.m. It read in pertinent part, Preparation: -The nurse on duty or designee shall obtain an appropriate order for discharge from the medical director; -If the resident is being discharged to the community or another facility, staff shall ensure that a discharge summary with a recapitulation of stay is completed and reviewed with the resident and/or resident representative, including teaching and discharge instructions, and that the discharge summary is provided to the provider at the next level of care; and, -If the resident is being discharged to a hospital, ensure that a discharge/transfer form, medication list, current history and physical, POLST (physician's order for life sustaining treatment) and bed hold notice are reviewed with the resident and/or resident representative prior to discharge to the extent reasonable and practical. A copy of these forms shall be sent with the resident to the hospital. The nurse on duty at the time of discharge shall complete a telephone report with the receiving facility. II. Resident #5 A. Resident status Resident #5, age greater than 65, was admitted on [DATE] and discharged to the hospital on 9/10/24. According to the September 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, chronic kidney disease, severe vascular dementia and type 2 diabetes mellitus. The 8/20/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of zero out of 15. He required partial to moderate assistance with toileting hygiene and dressing and set-up assistance with eating, oral hygiene and personal hygiene. The assessment indicated the resident had hallucinations, delusions and verbal behaviors directed at others such as threatening, screaming and cursing at others. III. Record review Review of the 9/10/24 Nursing Home Notice of Involuntary Transfer or Discharge revealed Resident #5 was discharged /transferred to the hospital because the safety of individuals in the facility was endangered and the health of individuals in the facility would otherwise be endangered. -However, the hospital the resident was transferred to was documented on the transfer/discharge as the location the resident would be relocating to, which was not an appropriate discharge location. A 9/10/24 nurse progress note revealed the police had arrived at the facility to speak with Resident #5 about his aggressive behaviors. The ambulance was enroute as the resident would be going to the hospital. The family and attending medical doctor (MD) had been updated to the change and increased behaviors. The nurse had all the paperwork and was awaiting the ambulance. A second 9/10/24 nurse progress note revealed the ambulance had arrived and was taking Resident #5 to the hospital. The nurse would call and update his wife and the attending MD had been updated. The 9/11/24 post discharge interdisciplinary team (IDT) progress note revealed increased resident agitation and behavior resulting in multiple resident-to-resident altercations and each time the resident was sent to the emergency room (ER) he was cleared to come back to the facility. The resident was scheduled for one-on-one supervision and continued to behave aggressively which led to the final result of immediate discharge from the facility. The resident had three falls on 9/8/24 without injury but was very delusional, talking to an imaginary wife who was under the bed and he resisted using his assistive device. -However, review of Resident #5's electronic medical record (EMR) revealed there was no documentation to indicate the facility had reassessed the resident after his transfer to the hospital to determine if the resident was able to return to the facility. -There was no documentation in Resident #5's EMR to indicate what needs the facility could not meet after the resident's hospitalization . IV. Staff interview The NHA was interviewed on 9/24/24 at 4:50 p.m. The NHA said the facility did not have any physician discharge orders for Resident #5's involuntary facility-initiated discharge on 9/10/24. The NHA said the facility did not reassess the resident after his transfer to the hospital.

Based on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#5) of five residents reviewed for abuse out of 13 sample residents. Specifically, the facility failed to report an allegation of abuse involving Resident #5 to the State Agency. Findings include: I. Facility policy and procedure The Abuse policy, revised 6/11/24, was provided by the nursing home administrator (NHA) on 9/23/24 at 3:30 p.m. It read in pertinent part, Every resident has the right to be free from all forms of abuse: verbal, sexual, physical, mental, neglect, corporal punishment and involuntary seclusion. All occurrences of resident abuse, suspected abuse, neglect and injuries of unknown source shall be promptly reported to the facility abuse coordinator for investigation. Staff are encouraged to talk with supervisors, department heads, social services or the administrator about residents or situations they find difficult to manage, stressful or frustrating to mitigate the risk of conflict between staff and residents. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation of resident property are reported immediately, but no later than 2 (two) hours, after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides jurisdiction in long term care facilities and office of long term care ombudsman) in accordance with State law through established procedures. II. Resident #5 A. Resident status Resident #5, age greater than 65, was admitted on [DATE] and discharged to the hospital on 9/10/24. According to the September 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease with late onset, chronic kidney disease, severe vascular dementia, and type 2 diabetes mellitus. The 8/20/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. He required partial to moderate assistance with toileting hygiene and dressing and set-up assistance with eating, oral hygiene and personal hygiene. The assessment indicated the resident had hallucinations, delusions, and verbal behaviors directed at others such as threatening, screaming, and cursing at others. B. Record review A review of Resident #5's electronic medical record (EMR) revealed the following nurse progress notes: On 9/9/24 at 5:19 p.m. Resident #5 struck another resident as she walked by in the dining room. The action was unprovoked. The other resident was not injured, but expressed frustration. The incident was reported by a certified nurse aide (CNA). On 9/10/24 at 9:37 a.m. Resident #5 was witnessed by a nurse and CNA to have shoved, with all his strength, another female resident who was sitting in her wheelchair into a group of residents, particularly another male resident with a front wheeled walker. Resident #5 also grabbed the arm of another female resident in an abrupt manner. On 9/10/24 at 11:18 a.m. Resident #5 grabbed another female resident and attempted to yank the resident by the arm to make her stand. -The facility was unable to provide documentation that the facility had reported the incidents of potential abuse to the State Agency. III. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 9/24/24 at 2:30 p.m. CNA #1 said she was educated on types of abuse and abuse reporting. CNA #1 said if she observed a resident being abused she would report the abuse immediately to the director of nursing (DON) or the assistant director of nursing (ADON). She said would also report suspected abuse to the NHA. Registered nurse (RN) #1 was interviewed on 9/24/24 at 3:00 p.m. RN #1 said if a resident forcefully grabbed another resident's arm and tried to aggressively pull the other resident she would report the incident as abuse. RN #1 said she would tell the NHA or DON. She said she would call the NHA if the NHA was not in the building. The NHA was interviewed on 9/24/24 at 3:30 p.m. The NHA said the documented incidents of alleged abuse involving Resident #5 were not reported, but the facility would report and investigate the allegation. The NHA was interviewed again on 9/24/24 at 7:00 p.m. and said she would report the alleged abuse involving Resident #5. IV. Facility follow up The facility reported the allegations of abuse (see above) to the State Agency on 9/24/24, after the completion of the survey.

Based on observations, record review and interviews, the facility failed to promote and maintain resident dignity for two (#35 and #51) of three residents reviewed out of 49 sample residents by providing care in a dignified, respectful and individualized manner. Specifically, the facility failed to: -Ensure Resident #35 was provided meal assistance in a dignified manner; and, -Ensure Resident #51 was treated with dignity and respect when asking for assistance. Findings include: I. Facility policy The Dignity policy, revised February 2021, was provided by the nursing home administrator (NHA) on 7/31/24 at 4:44 p.m. It read in pertinent part, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. When assisting with care, residents are supported in exercising their rights. For example, residents are provided with a dignified dining experience. Residents may exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with this facility. II. Resident #35 A. Resident status Resident #35, age less than 65, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke), dysphagia (difficulty swallowing) following cerebral infarction, bipolar disorder, post-traumatic stress disorder and ataxia (neurological disorder causing lack of coordination and tremors). The 7/16/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required set-up assistance for eating and substantial assistance for personal hygiene and dressing. B. Resident observations and interview On 7/28/24 at 5:49 p.m. certified nurse aide (CNA) #3 was observed assisting Resident #35 with her supper. Resident #35 was sitting in her wheelchair while CNA #3 stood beside the resident preparing her tray and assisting her with eating. Resident #35 was interviewed on 7/30/24 at 8:57 a.m. Resident #35 said sometimes the facility staff sat down when they assisted her with meals, but she said they primarily stood over her. Resident #35 said she preferred when the staff would sit down to assist her with eating. She said there was a folding chair in her room for the staff to sit in when they assisted her. On 7/30/24 at 12:31 p.m. the occupational therapist (OT) was assisting Resident #35 with lunch. The OT stood over the resident, cutting up her food and provided the resident with cueing. The resident had difficulty feeding herself due to tremors (uncontrolled muscle contractions causing shakiness) in her hands. -A folding chair was observed in the room, folded up by the dresser, however, the OT did not attempt to use the chair. On 7/31/24 at 8:34 a.m. CNA #4 was delivering breakfast to Resident #35. CNA #4 did not set up the tray for Resident #35 and started assisting the resident's roommate with eating. Resident #35 attempted to feed herself but was dropping eggs onto her lap due to her hand tremors. Resident #35 told CNA #4 she was frustrated and asked for help. When CNA #4 was finished assisting the resident's roommate, she went over and stood beside Resident #35 and assisted her with eating her breakfast. -A folding chair was observed in the room by the dresser, however, CNA #4 did not attempt to use the chair. Resident #35 was interviewed on 7/31/24 11:12 a.m. Resident #35 said when the facility staff stood when providing her assistance with eating, she felt belittled. Resident #35 said she was belittled her whole life and she would feel better if staff sat down on her level when they were assisting her with eating. C. Record review The self-care care plan, updated 7/30/24, documented Resident #35 fed herself with the use of a scoop lipped plate, black handled weighted utensils and a two handled mug with spouted lid. The 7/9/24 provider visit note documented Resident #35 reported her tremors remained impactful to her life and she had difficulty holding objects. The resident had requested to see a neurologist for worsening tremors and some further testing. The July 2024 CPO documented the resident received the following medication: Propranolol 10 mg (milligrams) three times a day for dystonic tremor (caused by involuntary muscle contractions), ordered on 6/10/24. D. Staff interviews The OT was interviewed on 7/30/24 at 12:34 p.m. The OT said she was trying a new scoop plate and weighted silverware with Resident #35. The OT said Resident #35 still needed help with eating some foods due to her tremors. CNA #4 was interviewed on 7/31/24 at 11:55 a.m. CNA #4 said she was taught to let residents try to eat on their own and only assist if they asked for help. CNA #4 said when assisting in the dining room, she sat down with the resident but she stood when assisting Resident #35 because there was not a chair in the room. She said she did not see the folding chair in Resident #35's room. The director of nursing (DON) was interviewed on 7/31/24 at 3:07 p.m. The DON said when staff assisted residents with eating, they should sit down to ensure they were not standing over the resident and providing a dignified dining experience. She said staff should sit down when assisting Resident #35 with meals. 38185 III. Resident #51 A. Resident status Resident #51, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the July 2024 CPO, diagnoses included hemiplegia (paralysis of one side of the body) following a cerebral infarction (stroke - disrupted blood flow to the brain due to problems with blood vessels that supply it) affecting the left non-dominant side. The 6/19/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He required setup assistance with all activities of daily living (ADL). B. Resident interview Resident #51 was interviewed on 7/29/24 at 10:11 a.m. Resident #51 said the facility staff were rude at times. He said, for example, he had pushed his call light and asked licensed practical nurse (LPN) #5 to assist him with putting the blanket over the bottom of his feet. He said LPN #5 refused to help him and told him he was able to do it himself and she would stand there and watch. Resident #51 said he did not understand why LPN #5 could not just help him with the blanket instead of being rude. He said he was blamed for being rude to the facility staff but it was often a reaction to how he was treated by the staff. C. Record review The 7/8/24 nursing progress note, documented by LPN #5, revealed Resident #51 activated his call light and asked LPN #5 to cover his feet with the blanket. LPN #5 documented she told the resident that he could actually put the blanket over his feet on his own and there was no need to call anybody to do that for him. Resident #51 responded he could do it himself but he chose not to. The progress note documented LPN #5 educated Resident #51 and told him she would observe the resident putting the blanket over his feet independently. LPN #5 documented she told the resident he had to help himself if he wanted to get well. D. Staff interviews The NHA was interviewed on 7/31/24 at 3:04 p.m. The NHA said all residents should be treated with dignity and respect. She said all residents should be assisted if they asked for help, whether or not they were independent. The NHA said she read the progress note documented by LPN #5 on 7/29/24. She said LPN #5 should have assisted Resident #51 to cover his legs with the blanket. She said there was no need for LPN #5 to be rude to Resident #51. She said the facility staff should be helpful.

Based on observations, record review and interviews, the facility failed to ensure food items were stored and served under sanitary conditions in the main kitchen. Specifically, the facility failed to ensure staff correctly and accurately tested for the correct parts per million (ppm) of the dishwasher, chemical sanitizer solution of the three sink compartments and sanitizer buckets. Findings include: I. Professional reference According to The Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 8/8/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view, Chemical sanitizers that are used to sanitize equipment and utensils shall be provided and available for use during all hours of operation. A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times and be used in accordance with the Environmental Protection Agency (EPA) registered label use instructions. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. II. Facility policy and procedure The Warewashing Kitchen Sanitation policy, revised September 2017, was provided by the nursing home administrator (NHA) on 7/31/24 at 4:35 p.m. It read in pertinent part, All dishware, serviceware, and utensils will be cleaned and sanitized after each use. The dining services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware. Temperature and sanitizer concentration logs will be completed, as appropriate. III. Observations and interviews On 7/29/24 at 9:10 a.m., dishwasher (DW) #1 was in the dishwashing area working on filling a rack with dirty dishes to run through the dishwasher. DW #1 said the dish machine was a low temperature machine. He said he checked the chemical concentration of the machine at the beginning of his shift and documented the outcome on a test trip log hanging on the wall in the dishwashing room. DW #1 ran a test strip through the dishwasher and the strip registered 10 ppm. The DW said the solution tested 100 ppm in the morning (7/29/24) and the machine needed to be primed. DW #1 said the solution in the red and green buckets was used to clean equipment and surfaces in the food preparation area and the dining room. The solution in the bucket was tested with a test strip by the DW. The solution registered 10 ppm on the strip. Dietary aide (DA) #1 said she did not check the chemical concentration of the sanitizer when she filled the bucket with the sanitizer solution. The dietary account manager (DAM) said the kitchen had an automatic solution dispenser that mixed the solution with water. He said they did not tamper with the dispenser and would call (name of company) for all maintenance issues. The DAM said the staff used the machine to fill the red sanitizer buckets. He said the staff needed to test the solution each time they filled the buckets to ensure the strength of the solution was correct by testing the ppm. He said the kitchen staff should document the test strip result each time they filled the red sanitizer buckets, however, he said there was no test strip log for the red sanitizing buckets. At 9:30 a.m. the DAM tested the three sink compartment chemical sanitizer solutions with a test strip and it registered 200 ppm. The DAM said he called the (name of company) who were the manufacturers of the dispenser and the chemical sanitizing solution. DW#1 primed the dishwasher and completed another test strip which measured 100 ppm. IV. Record review A review of the July 2024 (7/1/24 to 7/29/24) sanitizing test strip log on 7/31/24 at 9:50 a.m. revealed the log was completed once a day in the morning. The label on the sanitizing chemical solution dispenser read (Oasis multi quat sanitizer) the concentration of the sanitizer should measure 150 ppm. The manufacturer's recommendation from the (name of company) technician was to test the ppm at least three times a day to ensure the accuracy of the chemical solution. V. Staff interviews The DAM and the regional dietary account manager (RDM) were interviewed together on 7/30/24 at 3:55 p.m. The DAM said he had noticed the testing strip was completed only once a day when he started as the manager a few weeks ago, which was contrary to the manufacturer's recommendation for testing at least three times per day. The DAM said he was now aware of the recommendation and would follow the manufacturer's recommendations of running the test strip at least three times a day. The RDM said the facility would immediately educate the kitchen staff on how to test the quat solution correctly and would ensure testing strips were completed and documented accurately. The NHA was interviewed on 7/31/24 at 2:50 p.m. The NHA said the kitchen staff should ensure the chemical sanitizing solution was measured accurately before using it on equipment and surfaces in the food preparation area and in the dining room where residents ate. She said testing needed to be conducted accurately to ensure surfaces were sanitized appropriately to avoid contaminating the food preparation areas. The NHA said she would immediately reach out to (name of company) to offer additional training for the kitchen staff on the proper use and maintenance of the dishwasher and the management of the testing strips.

Based on observations, record review and interviews, the facility failed to ensure residents consistently receive food prepared by methods that conserved nutritive value and was palatable in taste, texture, appearance and temperature. Specifically, the facility failed to ensure the residents' food was palatable in taste, texture, appearance and temperature. Findings include: I. Resident interviews Resident #24 was interviewed on 7/29/24 at 9:00 a.m. Resident #24 said he preferred eating in his room. He said the room trays were always delivered about 15 minutes to 45 minutes late. Resident #24 said he received a texture modified diet and sometimes the staff delivered the wrong diet tray to him. Resident #21 was interviewed on 7/29/24 at 9:02 a.m. Resident #21 said she only ordered hamburgers and hot dogs from the kitchen because the rest of the food did not taste good. She said the hot dogs and hamburgers were usually served cold. She said they put barbeque sauce on the hamburgers and it did not taste right. Resident #51 was interviewed on 7/29/24 at 10:14 a.m. Resident #51 said the food tasted terrible and was always served late. He said the staff would always forget to provide condiments and he would have to ask the staff to get some for him. He said the tray sat longer and got cold while he waited for staff to bring him the condiments. Resident #40 was interviewed on 7/29/24 at 10:23 a.m. Resident #40 said the food tasted bad and was always served late. He said he went to dialysis every Monday, Wednesday and Friday. He said he left the facility at 4:30 p.m. and did not return until 9:45 p.m. He said the kitchen staff often forgot to make his dinner to take with him for his appointments and they would then offer him a peanut butter sandwich. Resident #40 said the sandwich often did not hold him and he would return to the facility feeling hungry. He said he got sick at the entrance of the facility when he returned from dialysis due to not eating enough food before his appointments. Resident #66 was interviewed on 7/29/24 at 11:19 a.m. Resident #66 said the food did not taste right and had no flavor. She said the drinks were watered down. Resident #5 was interviewed on 7/31/24 at 2:15 p.m. Resident #5 said the food was awful and tasted bad. He said he ate his meals in his room and the food was delivered to him cold. Resident #5 said the encrusted pork loin was overcooked and tasted dry. He said the gravy did not taste right because it tasted as if it was missing seasoning. II. Test tray A test tray for a regular diet and pureed diet was evaluated by four surveyors immediately after the last resident had been served their room tray for lunch on 7/31/24 at 1:22 p.m. The regular texture test tray consisted of encrusted pork loin, mashed potatoes, cabbage vegetables, diner rolls and sweet potatoes. The following observations were made: -The encrusted pork loin was dry; -The mashed potatoes were bland; -The gravy on the mashed potatoes and the pork loin tasted bland and was watery; and, -The cabbage vegetables were bland and mushy. The pureed texture test tray consisted of puree pork loin, mashed potatoes, puree cabbage, puree sweet potatoes with gravy and pureed green peas. The following observations were made: -The mashed potatoes tasted bland; -The gravy was watery and tasted bland; and, -The pureed pork loin tasted mushy and dry. III. Staff interviews The dietary account director (DAM) and the regional dietary manager (RDM) were interviewed together on 7/31/24 at 1:50 p.m. The DAM said he noticed the encrusted pork loin was a little overcooked. He said, because it was almost time to begin serving lunch, he did not have time to fix it. The DAM said the kitchen was running out of gravy in the middle of serving lunch so cook (CK) #1 asked him to prepare additional gravy. He said the additional gravy came out a little watery because it was prepared very quickly. The DAM said the cooks should always ensure they had enough of every menu item according to the census of the facility. The DAM said the kitchen staff should always taste the food items they prepared for the residents to ensure the appropriate texture and taste were obtained before serving the food to the residents. The RDM said it was important to ensure the right food texture and taste were obtained to avoid residents not eating their food, which could help to prevent unwanted weight loss. The RDM said more education would be provided immediately to the kitchen staff in regards to food preparation and palatability. The nursing home administrator (NHA) was interviewed on 7/31/24 at 2:50 p.m. The NHA said more education would be provided immediately to all kitchen staff and a monitoring plan would be initiated to ensure staff complied with the facility's food preparation protocol.

Based on interviews and record review, the facility failed to ensure residents on five of five hallways had the right to choose his or her own attending physician. Specifically, the facility failed to allow residents to choose their primary care provider (PCP) when the facility changed medical provider groups. Findings include: I. Facility policy and procedure The Choice of Attending Physician policy, reviewed February 2021, was provided by the nursing home administrator (NHA) on 7/31/24 at 4:44 p.m. It revealed in pertinent part, The resident has the right to choose his or her own attending physician. The resident is informed in writing of the name and contact information for his or her attending physician: during the admission process; any time the information changes; and upon the resident/representative's request. II. Resident and resident representative interviews The following residents, who were deemed to be cognitively intact based on facility assessment were interviewed and said the following: Resident #51 was interviewed on 7/29/24 at 10:11 a.m. Resident #51 said he had no idea his physician had been changed. He said the facility did not inform him nor obtain his permission. Resident #40 was interviewed on 7/29/24 at 10:19 a.m. Resident #40 said the facility staff never informed him that his physician had changed. He said a physician entered his room and told him that she was his new doctor. He said he told her he had not changed physicians and she responded that the facility had made the decision and he did not have a choice. Resident #40 said he was very upset that he was not given the choice for his medical provider and the facility had made the change without obtaining his consent. Resident #35 was interviewed on 7/29/24 at 10:56 a.m. Resident #35 said the facility did not inform her she was receiving a new physician nor obtain her consent. She said the facility just did whatever they wanted. Resident #21 was interviewed on 7/29/24 at 10:57 a.m. Resident #21 said the facility did not inform her about changing physicians nor obtain her consent. Resident #66 was interviewed on 7/29/24 at 11:13 a.m. Resident #66 said the facility did not ask her permission to change her physician. She said the facility never even informed her. She said the physician walked into her room one day and said she was her new doctor. Resident #2 was interviewed on 7/29/24 at 11:18 a.m. Resident #2 said the facility did not obtain her consent to change physicians. She said she was not informed of the change until the physician entered her room to speak with her. Resident #8 was interviewed on 7/29/24 at 12:14 p.m. Resident #8 said the facility did not inform him nor obtain his consent to change his physician. Resident #75's representative was interviewed on 7/29/24 at 12:30 p.m. The representative said she was not aware the resident's physician had changed. She said she had not heard from the new physician and the facility did not obtain her consent for the change. III. Group interview The group interview was conducted on 7/30/24 at 10:00 a.m. with Resident #11, #68, #54 and #66, who were identified as alert and oriented through facility and assessment. All of the residents said they had not been informed the facility had changed to a new medical provider group. The residents said they were not informed they would be receiving a new physician nor did the facility ask their permission. IV. Record review -The facility was unable to provide documentation that the residents and their responsible parties had been informed and that residents' permission was obtained to change resident physicians. V. Staff interviews The NHA was interviewed on 7/31/24 at 11:00 a.m. The NHA said the facility had changed their primary medical group on 6/1/24. She said it was a corporate decision and the facility administration was not given a choice. The NHA said she was not sure if residents were informed. She said a meeting was not held with residents, nor was a letter provided to inform them or obtain their consent. The regional clinical consultant (RCC) was interviewed on 7/31/24 at 11:15 a.m. The RCC said the facility was not given a choice when the physician medical group was changed on 6/1/24. She said it was a corporate decision and the residents were not informed nor was their consent obtained.

Based on observations and interviews, the facility failed to maintain a safe, comfortable and functional homelike environment for residents, staff and the public on four of five units. Specifically, the facility failed to provide the necessary maintenance services to ensure resident's room doors #205, #304, #306, #404, #405 and #607 were easily able to be opened and closed and damaged floors were repaired. Findings include: I. Facility policy and procedure The Homelike Environment policy, revised February 2021, was provided by the nursing home administrator (NHA) on 7/31/24 at 4:35 p.m. It revealed in pertinent part, Residents will be provided with a safe, clean, comfortable and homelike environment. II. Observations On 7/30/24 at 9:22 a.m. resident room [ROOM NUMBER] was observed. There were several dark stains on the floor caused by the room's door not being able to close properly. The door to the room was difficult to open and close. At 9:29 a.m. resident room [ROOM NUMBER] and room [ROOM NUMBER] were observed. The residents' bedroom doors were not aligned properly making the doors difficult to open and close. At 9:36 a.m. room [ROOM NUMBER] was observed. There was missing paint and chipped paint on the door and door frame. At 9:40 a.m. room [ROOM NUMBER] was observed. There was missing paint and chipped paint on the door and door frame. At 9:46 a.m. room [ROOM NUMBER] was observed. There was missing paint and chipped paint on the door and door frame. At 9:50 a.m. the main dining room was observed. There was missing flooring by the main entrance to the dining room. III. Resident interviews Resident #51, who resided in room [ROOM NUMBER], was interviewed on 7/31/24 at 9:45 a.m. Resident #51 said the bedroom doors had been hard to open and close for several months. He said he had reported the door issue to the staff and nothing had been done about it. The resident said he saw the staff struggle to open and close the doors on several occasions. Resident #51 said he would have preferred having a new room until the door was fixed but no one had offered him the option to move to a safer room with easy to open and close doors. Resident #59, who resided in room [ROOM NUMBER], was interviewed on 7/31/24 at 10:15 a.m. Resident #59 said the bedroom door was hard to open and close for several months. He said he had to lift the door with both hands to get it to close or open. Resident #59 said he was not offered an alternative room. IV. Staff interviews Certified nurse aide (CNA) #8 was interviewed on 7/31/24 at 9:50 a.m. CNA #8 said most of the residents' room doors were hard to open and close. She said most of the time it required significant effort to get the doors open. CNA #8 said the door issue had been reported to the maintenance supervisor (MS) on several occasions and the staff had been informed that the facility was in the process of replacing them. The MS and the NHA were interviewed together on 7/31/24 at 10:00 a.m. The NHA said the facility had identified residents' rooms that had defective doors and the facility would be replacing them. The MS said it was a safety concern when the residents could not open and close their bedroom doors with ease. The NHA said some of the doors had been replaced and the remaining doors were scheduled to be replaced on 8/8/24.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for three (#35, #43 and #66) of eight residents out of 49 sample residents. Specifically, the facility failed to: -Ensure safe smoking practices were followed, including adequate supervision, for Resident #35; -Ensure a thorough investigation was completed after Resident #35 burned her fingers while smoking; and, -Ensure medications were not left at the bedside without appropriate self-administration assessments for Resident #35, Resident #43 and Resident #66. Findings include: I. Facility policy and procedure The Smoking policy, dated 5/10/23, was provided by the nursing home administrator (NHA) on 7/31/24 at 4:44 p.m. It read in pertinent part, Supervised smokers shall not be permitted to smoke without the direct supervision of a designated staff member, family member or volunteer. Direct supervision will be provided throughout the entire smoking period. The Medication Administration policy, dated 2/29/24, was provided by the NHA on 7/31/24 at 4:44 p.m. It read in pertinent part, Medications are administered in accordance with written orders of the attending physician or physician extender, Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with the guidelines for self-administration of medication. The Self-Administration of Medication policy, dated February 2021, was provided by the NHA on 7/31/24 at 4:44 p.m. It read in pertinent part, As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. II. Resident #35 A. Resident status Resident #35, age less than 65, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke), dysphagia (difficulty swallowing) following cerebral infarction, bipolar disorder, post-traumatic stress disorder and ataxia (neurological disorder causing lack of coordination and tremors). The 7/16/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment indicated Resident #35 needed set-up assistance for eating and substantial assistance for personal hygiene and dressing. B. Resident observations On 7/29/24 at 5:48 p.m. a medication cup containing three medication capsules was observed on Resident #35's overbed table. The resident was sitting in her wheelchair at the table waiting for her supper. On 7/31/24 at 8:31 a.m. a medication cup containing three medication capsules was observed on Resident #35's overbed table. The resident said it was her Creon (a medication used to treat insufficient pancreas function) and the night nurse left it for her to take with breakfast. Resident #35 was observed taking the medications without assistance. C. Resident interviews Resident #35 was interviewed on 7/29/24 at 2:44 p.m. She said she burned her fingers while smoking about a month ago (June 2024). Resident #35 said when she burned her fingers she was smoking a cigarette and was unsupervised. Resident #35 was interviewed again on 7/31/24 10:52 a.m. Resident #35 said the nurses brought her Creon medication and left it on her table because she wanted it right when her meal came and the nurse was usually in the dining room at that time. She said sometimes she could take it herself and sometimes the nurse had to come back and help her due to her tremors. Resident #35 said usually stayed in her room until she took the medication. She said if she left her room before she took the medications, her roommate watched the pills for her. D. Record review The July 2024 CPO included a physician's order, dated 4/2/24, to give Resident #35's Creon to keep at bedside with meals so the resident could take the medication after the first bites of food. -The order was discontinued on 7/29/24, during the survey. -A review of Resident #35's electronic medical record (EMR) did not reveal a self-administration assessment was completed for the resident to self-administer the Creon, nor was it indicated on the resident's comprehensive care plan. The smoking assessment, completed 6/7/24 indicated Resident #35 was an unsafe smoker and required supervision. According to a progress note, dated 6/10/24, Resident #35 reported two burns to the nurse. The burns were located on her right second finger measuring 1 centimeter (cm) by 0.8 cm by 0.2 cm and on her right third finger measuring 3 cm x 1 cm x 0 cm. The risk management report, completed 6/10/24, indicated Resident #35 said she burned herself while smoking but did not know when it happened. According to the report, the resident obtained cigarettes from other sources and smoked on her own at times. -There was no documentation to indicate the facility had thoroughly investigated how or when Resident #35 burned her fingers when smoking. E. Staff interviews Licensed practical nurse (LPN) #5 was interviewed on 7/31/24 at 3:01 p.m. LPN #5 said she was the nurse for Resident #35. She said nurses left the Creon medication for Resident #35 so she could take it when her meal arrived. LPN #5 said the night nurse left the medication on the overbed table this morning (7/31/24) around 7:25 a.m. -Resident #35 was not observed taking the medication until 8:31 a.m. The DON was interviewed on 7/31/24 at 2:35 p.m. The DON said Resident #35 came to her and showed her the burns on her fingers on 6/10/24. The DON said she did not know how the burns happened because Resident #35 was only supposed to be smoking electronic cigarettes at that time. The DON said the facility did not interview the staff who had taken Resident #35 out for smoke breaks to determine if she was smoking regular cigarettes prior to the burns being found. The DON said all of Resident #35's smoking materials should be locked up in a lock box or with the nurse and she should not have a lighter. The DON said Resident #35 sometimes got cigarettes from her roommate or other residents and she sometimes left the building with friends and would smoke regular cigarettes with them. The DON was interviewed again on 7/31/24 at 3:07 p.m. The DON said the nurses were leaving the Creon medication at the bedside for Resident #35 about one half hour before meals. However, the DON said the physician's order had been discontinued on 7/29/24 because Resident #35 was too shaky and needed assistance with taking her medication. The DON said the Creon should not have been left at the bedside today (7/31/24). -The Creon was left at the bedside 7/29/24 and 7/31/24, after the order had been discontinued. Certified nurse aide (CNA) #7 was interviewed on 7/31/24 at 1:10 p.m. CNA #7 said she knew who the regular smokers were and which residents needed a smoking apron. She said there was not a list of who was a supervised smoker because all smokers were to be supervised and could go out only during smoking times. CNA #7 said Resident #35 was a supervised smoker when she burned her fingers. CNA #7 said she did not know how it happened but said Resident #35 was only able to smoke electronic cigarettes now. The NHA was interviewed on 7/31/24 at 2:11 p.m. The NHA said a smoking assessment was completed quarterly for all residents. The NHA said if a resident was a safe smoker they could go outside to smoke anytime and they had a lock box in their room to keep smoking materials. The NHA said if a resident was determined to be an unsafe smoker the staff kept their smoking materials and they could go outside to smoke only at designated times with staff supervision. The NHA said staff must stay with the supervised smokers the entire time the residents were smoking. The NHA said she did not recall what was found on the accident investigation for Resident #35. 38185 III. Resident #43 A. Resident status Resident #43, age 76, was admitted on [DATE] and readmitted on [DATE]. According to the July 2024 CPO, diagnoses included chronic kidney disease, post-traumatic stress disorder, major depressive disorder, anxiety disorder, low back pain and restless leg syndrome. The 7/2/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required set up assistance with activities of daily living (ADL). B. Resident interview and observations On 7/29/24 at 11:16 a.m. Resident #43 was lying in bed watching television. On the overbed table, next to the resident's bed, three different bottles of eye drops were observed, along with a bottle of nasal spray and dairy relief pills. Resident #43 said her eyes were really dry and she administered the eye drops daily. She said she used the nasal spray a couple of times per week and she took the dairy relief pills when she ate anything that consisted of dairy products. On 7/30/24 at 4:15 p.m. Resident #43 was lying in bed watching television. Resident #43 described the three bottles of eye drops as Systane Lubricant eye drops, Systane Gel eye drops and Eye Allergy Itch Relief (Olopatadine Hydrochloride Ophthalmic Solution). She said the Systane eye drops were given to her by her ophthalmologist and her family member provided her with the allergy eye drops. Resident #43 said she used both of the Systane eye drops after she was given the prescription eye drops by the nurse every day. Resident #43 said the nasal spray was Deep Sea Premium Saline, which she used when her allergies were acting up. She said she used the Dairy Relief Lactase Enzyme/Dietary Supplement whenever she consumed food with dairy products. During the interview with Resident #43, Resident #55, who had severe cognitive impairment and a documented history of wandering, entered Resident #43's room. Resident #55 was speaking Spanish and appeared aggressive. Resident #43 told Resident #55 to leave her room in Spanish. Resident #55 continued to come into the room, until Resident #43 continued to yell, vamanos, vamanos, vamanos. Resident #55 ended up leaving Resident #43's room. Resident #43 said Resident #55 and another resident would enter her room quite often. She said the two residents wandered up and down the hallways, entering everyone's rooms. Resident #43 said her roommate, Resident #66, tried to give her some Aspercreme spray, but she did not think it was right to use since she did not know what it was (see observations below for Resident #66). C. Record review -The July 2024 CPO did not reveal a physician's order for the Systane Lubricant eye drops, the Systane Gel eye drops, Eye Allergy Itch Relief eye drops, Deep Sea Premium Saline nasal spray or Dairy Relief Lactase Enzyme/Dietary. -A review of Resident #43's EMR did not reveal a self-administration assessment was completed for the resident to self-administer medications, nor was it indicated on the resident's comprehensive care plan. IV. Resident #66 A. Resident status Resident #66, age 71, was admitted on [DATE] and readmitted [DATE]. According to the July 2024 CPO, diagnoses included chronic respiratory failure with hypoxia (progressive condition that occurs when the airways to the lungs become damaged and narrow, restricting airflow and oxygen intake), polyneuropathies (damage to peripheral nerves), pain in the left shoulder and displaced fracture of the lateral end of the left clavicle. The 7/24/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was independent with all ADLs. B. Resident interview and observations On 7/29/24 at 11:16 a.m. Resident #66 was lying in bed watching television. Resident #66 and Resident #43 were roommates. On Resident #66's overbed table, a can of Aspercreme Lidocaine maximum strength dry spray was observed with the lid off. Resident #66 said she used the Aspercreme Spray when she was having muscle pain. C. Record review -The July 2024 CPO did not reveal a physician's order for the Aspercreme Lidocaine Spray. -A review of Resident #66's EMR did not reveal a self-administration assessment was completed for the resident to self-administer the Aspercreme Spray, nor was it indicated on the resident's comprehensive care plan. V. Staff interviews LPN #5 was interviewed on 7/30/24 at 4:25 p.m. LPN #5 said she did not know if residents should have medications at the bedside. She said she did not know who was responsible for conducting self-administration assessments. LPN #5 said she was not sure if either Resident #43 or Resident #66 had a self-administration assessment. She said she did not know how to find that information. The DON was interviewed on 7/31/24 at 11:20 a.m. The DON said all medications kept at the bedside should have a physician's order for self administration, a self-administration assessment completed and be noted on the comprehensive care plan. She said all medications that the resident requested to have in their room should be kept in a lock box to ensure another resident did not access them by accident. The DON said Resident #43 did not have a physician's order to self-administer medications nor a physician's order for the eye drops, nasal spray and daily relief supplement. She said Resident #66 did not have a physician's order to self-administer medications nor a physician's order for the Aspercreme Lidocaine spray. The DON said the facility did not complete self-administration assessments for Resident #43 and Resident #66. She said the comprehensive care plan did not include self-administration for Resident #43 and Resident #66. The DON said the facility was in the process of obtaining physician's orders for the medications, completing the self-administration assessments, updating the comprehensive care plans and providing lock boxes for Resident #43 and Resident #66.

Based on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in three of five medication carts and one of two medication storage rooms. Specifically, the facility failed to: -Ensure medications were properly labeled with open dates; and, -Ensure expired medications were removed from the medication carts and the medication storage room. Findings include: I. Professional reference The United States Food and Drug Administration (USFDA) (2/8/21) Don't Be Tempted to Use Expired Medicines, was retrieved on 8/6/24 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it. II. Observations On 7/31/24 at 8:48 a.m. the medication cart on the 200 hallway was observed with licensed practical nurse (LPN) #2. The following item was found: -An open Tresiba FlexTouch insulin pen 100 units/milliliter was not labeled with the date it was opened. On 7/31/24 at 9:47 a.m. the medication cart on the 500 hallway was observed with LPN #4. The following item was found: -One bottle of liquid haloperidol 2 milligrams (mg)/milliliter (ml) that expired on 6/24/24. On 7/31/24 at 10:14 a.m. the medication storage room was observed with the director of nursing (DON). The following item was found in the refrigerator: -Three one mg vials of lorazepam liquid 2 mg/ml single dose that expired on 4/18/24. On 7/31/24 at 11:24 a.m. the medication cart on the 300 hallway was observed with LPN #3. The following items were found: -One bottle of Tylenol 500 mg that expired in June 2024; and, -One bottle of Stress Formula vitamin supplement that expired in April 2024. On 7/31/24 at 11:46 a.m. the medication cart on the 200 hallway was observed with LPN #2. The following item was found: -One vacutainer blood collection needle that expired 10/31/23. III. Staff interviews LPN #2 was interviewed on 7/31/24 at 8:48 p.m. LPN #2 said the insulin pen should have been dated when it was opened. LPN #2 said she was unsure how long an insulin pen was good for after it was opened. LPN #3 was interviewed on 7/31/24 at 11:24 a.m. LPN #3 said he checked for expired medications in the cart. He said the expired medications should have been removed from the medication cart. The director of nursing (DON) was interviewed on 7/31/24 at 4:00 p.m. The DON said the expired medications and supplies should have been removed from the medication storage room refrigerator and medication carts. The DON said the insulin pen should have been dated when it was opened.

Based on observation, and interviews the facility failed to follow infection control measures to prevent the potential cross contamination of [CONDITION(S)]-CoV-2 COVID-19, during testing procedures while the facility was in outbreak. Observations and interviews revealed the facility failed to follow infection control procedures per Centers for Disease Control (CDC) guidance while performing polymerase chain reaction (PCR) testing for [CONDITION(S)]-CoV-2 COVID-19, on both resident and staff. The nurse performing the testing on 11/15/21 failed to: -Wear proper personal protective equipment (PPE), including a National Institute for Occupational Safety and Health (NIOSH) approved N-95 mask, protective gown consistently and properly when collecting [CONDITION(S)]-C0V-2 COVID-19 specimen from staff and residents; -Properly disinfect eye protection when soiled or contaminated, during the procedure and before leaving the testing site to perform other duties within the facility; -Protect other individuals and equipment and supplies located within three feet of the testing area from aerosolized droplets expelled during the testing procedures; -Disinfect the testing/ specimen collecting area hourly, when soiled and before leaving the testing site unattended to prevent cross contamination and contaminants from spreading; and, -Perform hand hygiene after touching mask and face shield. The facility failures beginning 11/15/21, created an immediate jeopardy situation, a situation that was preceded by the facility's outbreak status where three actively working staff members had tested positive for COVID-19 just days earlier. Due to the facility's failures, it created a situation of immediate jeopardy with the potential of serious harm that additional staff and or resident could have become infected with COVID-19, due to exposure to contaminated surfaces/objects or aerosolized [CONDITION(S)] particles during and after the facility-wide testing process. Findings include: I. Facility status [CONDITION(S)]-CoV-2 COVID-19 The facility was in outbreak status starting on 11/12/21, as confirmed by the facilities local County Health Department (CHD). As of 11/19/21, four actively working facility staff had tested positive for [CONDITION(S)]-CoV-2 COVID-19. As of 11/18/21, no resident had tested positive for [CONDITION(S)]-CoV-2 COVID-19. -Certified nurse aide (CNA) #6 was fully vaccinated. CNA #6 started experiencing [MEDICATION(S)] like symptoms on 11/2/21 and called off work CNA #6's symptoms worsened and the CNA went to a non-facility testing site on 11/6/21 and received a PCR test for COVID-19; the results were positive. CNA #6 was the first of staff and residents to test positive. CNA #6's last day of work was 11/2/21. -Activities assistant (AA) #2 was unvaccinated working under a religious waiver. AA #2 was not experiencing any symptoms but had been tested daily, by rapid point of care testing (POC) prior to each shift all POC tests up through 11/11/21 were negative. As a part of facility wide outbreak testing, AA #2 tested positive by PCR testing done on 11/8/21 with results reported on 11/12/21. AA #2 had worked in the facility up through 11/11/21 while she waited for the PCR result to be revealed. -Dietary aid (DA) #1 was fully vaccinated. DA #1 was not experiencing any COVID-19 like symptoms, and was not undergoing daily POC testing due to vaccination status. DA #1 was however given a PCR [CONDITION(S)]-CoV-2 COVID-19 test starting on 11/8/21, as a part of the mandatory full scale outbreak testing. During second round testing on 11/15/21, DA #1's PCR test result came back on 11/17/21 revealing positive results for [CONDITION(S)]-CoV-2 COVID-19. DA #1's last day of work was 11/13/21. The facility had three unvaccinated residents refusing the vaccine and six unvaccinated staff who had a religious waiver. II. Immediate Jeopardy A. Findings of immediate jeopardy Observations and interviews revealed the facility failed to follow infection prevention measures to prevent cross contamination and spread of [CONDITION(S)]-CoV-2 COVID-19, as required during mandatory testing on all staff and residents during a facility outbreak of [CONDITION(S)]-CoV-2 COVID-19. The facility's failure to follow outbreak testing requirements created an immediate jeopardy situation due to the likelihood the facility's failures would lead to transmission of [CONDITION(S)]-CoV-2 COVID-19. B. Facility notice of immediate jeopardy On 11/15/21 at 4:50 p.m., the nursing home administrator (NHA) and clinical consultant (CC) were notified that the failures in the facility's infection control program and testing created an immediate jeopardy situation that placed all residents in the facility at risk for serious harm related to [CONDITION(S)]-CoV-2 COVID-19. C. Plan to remove immediate jeopardy On 11/15/21 at 5:57 p.m., CC presented the following final plan to address the immediate jeopardy situation: Testing was completed for 11/15/21; in preparation for the next scheduled round of mandatory outbreak testing: 1. The regional nurse consultant (RNC) will educate the director of nursing (DON) and Infection preventionist (IP) on regulatory compliance and proper techniques for collecting lapidary specimens for [CONDITION(S)]-CoV-2 COVID-19. 2. Identification all residents affected or likely to be affected by current [CONDITION(S)]-CoV-2 COVID-19 testing procedures: a. The DON and IP will; identify actions that were performed to address any effects the resident had suffered, are likely to suffer, or any serious adverse outcome as a result of the facility's noncompliance. Start date: 11/15/21. b. Nursing staff will assess all residents for signs or symptoms of [CONDITION(S)]-CoV-2 COVID-19. Start date: 11/15/21. 3. Actions to prevent occurrence/recurrence: a. The DON and IP will immediately review policies to ensure appropriate procedures for the next round of [CONDITION(S)]-CoV-2 COVID-19 testing are in place to prevent harm and potential harm. Start date: 11/15/21. b. The DON and IP will develop and implement new policy and procedure as applicable to ensure additional serious harm will be prevented. Start date: 11/15/21. c. The DON and IP will [MEDICATION(S)] to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring. Start date: 11/15/21. d. The DON and IP will provide all nurses both registered nurses (RN) and licensed practical nurses (LPN) education regarding proper methods of testing and collecting specimens for [CONDITION(S)]-CoV-2 COVID-19 and continue until all nurses have been reeducated. Start date: 11/15/21. All nurses will be educated on: -Wearing appropriate PPE while collecting [CONDITION(S)]-CoV-2 COVID-19 samples for testing; to include the wearing of protective gowns, N95 mask, and eye protection. -Securing the testing area by closing the door or providing a shielded area to the testing area to prevent cross contamination while collecting nasal swab specimens from each individual being tested . -Proper techniques and timing to applying the appropriate types of PPE in preparation for collecting a nasal swab specimen while testing for [CONDITION(S)]-CoV-2 COVID-19; proper techniques for removal of PPE in between collecting samples for each test subject and when ending the testing procedures and moving to other tasks within the facility. -The need to remove/change PPE during the testing procedures if the PPE becomes soiled or contaminated. -Ensuring the testing area was properly disinfected hourly during testing and before leaving the testing site unmonitored for any length of time. e. The DON and IP will monitor PCR testing procedures during the duration of the facility's [CONDITION(S)]-CoV-2 COVID-19 outbreak to verify compliance and record findings on a compliance checklist. Start date: 11/15/21. D. Removal of immediate jeopardy On 11/15/21 at 6:11 p.m. the NHA was notified the immediate jeopardy was lifted based on evidence of the facility's implementation of the above plan. However, deficient practice remained at an F level, widespread potential for more than minimal harm. III. Facility failure to follow [CONDITION(S)]-CoV-2 COVID-19 testing guidance A. [CONDITION(S)]-CoV-2 COVID-19 outbreak testing guidance CDC guidance, Guidance for [CONDITION(S)]-CoV-2 Point-of-Care and Rapid Testing, updated 7/8/21, available from:https://www.cdc.gov/coronavirus/2019-ncov/lab/point-of-care-testing.html#anchor_ 947, accessed on 11/15/21. It read in pertinent part: Rapid point-of-care tests provide results within minutes (depending on the test) and are used to diagnose current or detect past [CONDITION(S)]-CoV-2 infections in various settings, such as: Long-term care facilities and nursing homes. Specimen Collection & Handling of Point-of-Care and Rapid Tests -Proper specimen collection and handling are critical for all COVID-19 testing, including those tests performed in point-of-care settings. A specimen that is not collected or handled correctly can lead to inaccurate or unreliable test results. For personnel collecting specimens or working within 6 feet of patients suspected to be infected with [CONDITION(S)]-CoV-2, maintain proper infection control and use recommended personal protective equipment (PPE), which could include an N95 or higher-level respirator (or face mask if a respirator is not available), eye protection, gloves, and a lab coat or gown. Disinfect surfaces within 6 feet of the specimen collection and handling area before, during, and after testing and at these times: -Before testing begins each day -Between each specimen collection -At least hourly during testing -When visibly soiled -In the event of a specimen spill or splash -At the end of every testing day CDC recommends the following practices when performing point-of-care tests: Before the Test -Perform a risk assessment to identify what could go wrong, such as breathing in infectious material or touching contaminated objects and surfaces. -Implement appropriate control measures to prevent these potentially negative outcomes from happening. -Use a new pair of gloves each time a specimen is collected from a different person. If specimens are tested in batches, also change gloves before putting a new specimen into a testing device. Doing so will help to avoid cross-contamination. -After the Test Decontaminate the instrument after each use. Follow the manufacturer ' s recommendations for using an approved disinfectant, including proper dilution, contact time, and safe handling. -Handle laboratory waste from testing [CONDITION(S)]-CoV-2 specimens in the same manner as all other biohazardous waste in the laboratory. Currently, there is no evidence to suggest that laboratory waste needs additional packaging or disinfection procedures. CDC guidance, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 9/10/21, available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, accessed on 12/1/21. It read in pertinent part: This guidance is applicable to all U.S. settings where healthcare is delivered. Employers should be aware that other local, state, and federal requirements may apply, including those promulgated by OSHA. Ensure everyone is aware of recommended IPC practices in the facility. Implement Source Control Measures -Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person ' s mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. NIOSH-approved N95 or equivalent or higher-level respirators should be used for: -All aerosol-generating procedures Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. Optimize the Use of Engineering Controls and Indoor Air Quality -Optimize the use of engineering controls to reduce or eliminate exposures by shielding health care professionals (HCP) and other patients from infected individuals (e.g., physical barriers at reception / triage locations and dedicated pathways to guide symptomatic patients through waiting rooms and triage areas). Aerosol Generating Procedures (AGPs) -Procedures that could generate infectious aerosols should be performed cautiously and avoided if appropriate alternatives exist. -AGPs should take place in an airborne infection isolation room (AIIR), if possible. -The number of HCP present during the procedure should be limited to only those essential for patient care and procedure support. Visitors should not be present for the procedure. Environmental Infection Control -Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product ' s label) are appropriate for [CONDITION(S)]-CoV-2 in healthcare settings, including those patient-care areas in which aerosol generating procedures are performed. B. Facility policy The Personal Protective Equipment policy, dated 3/1/2020, was provided by the NHA on 11/15/21 at 4:10 p.m., it read in pertinent part: This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors, and other staff. -All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials was likely. PPE will be utilized as part of standard precautions regardless of a resident's suspected or confirmed infection status. -Wear gloves when direct contact with blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated surfaces or equipment was anticipated. Perform hand hygiene before donning gloves and after removal. Gloves are not a substitute for hand hygiene. -Gowns should fully cover the torso from neck to knees, arms to end of wrist, and wrap around the back. Fasten in back at neck and waist. -Wear a mask to protect the face from contamination with blood, body fluids, and other potentially infectious materials during tasks that generate splashes or sprays. -The outside of goggles and face shields are contaminated. -Wear a NIOSH-approved N95 or higher-level respirator to prevent inhalation of pathogens transmitted by the airborne route. Staff will receive training on the why, what, and how of PPE upon hire, annually, when new products are introduced, and as needed. The Personal Protective Equipment policy, dated 3/1/2020, was provided by the NHA on 11/15/21 at 4:10 p.m., it read in pertinent part: This facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents , visitors, and other staff. -All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials was likely. PPE will be utilized as part of standard precautions regardless of a resident ' s suspected or confirmed infection status. -Wear gloves when direct contact with blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated surfaces or equipment was anticipated. Perform hand hygiene before donning gloves and after removal. Gloves are not a substitute for hand hygiene. -Gowns should fully cover the torso from neck to knees, arms to end of wrist, and wrap around the back. Fasten in back at neck and waist. -Wear a mask to protect the face from contamination with blood, body fluids, and other potentially infectious materials during tasks that generate splashes or sprays. -The outside of goggles and face shields are contaminated. -Wear a NIOSH-approved N95 or higher-level respirator to prevent inhalation of pathogens transmitted by the airborne route. Staff will receive training on the why, what, and how of PPE upon hire, annually, when new products are introduced, and as needed. The Coronavirus Testing policy dated 2021, was provided by the NHA on 11/16/21 at 11:12 a.m., it read in pertinent part: When testing of Staff and Residents in Response to an Outbreak. -A new COVID-19 infection in any staff or any nursing home onset COVID-19 infection in a resident will trigger an outbreak investigation. -Upon identification of a single new case of COVID-19 infection in any staff or residents, testing will begin immediately. -Outbreak testing will be performed either through contact tracing or broad-based (e.g. facility-wide) testing. -All staff and residents that test negative will be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. Conducting Testing -Specimens will be collected and, if necessary, stored in accordance with the manufacturer's instructions for use for the test and CDC guidelines. -The facility will maintain proper infection control and use recommended personal protective equipment (PPE), which includes a NIOSH approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves and a gown, when collecting specimens . -The facility will clean, disinfect, and maintain testing equipment in accordance with the manufacturer ' s instructions. The policy did not give details for methods of infection control procedures for preforming [CONDITION(S)]-CoV-2 COVID-19 testing. Per the NHA, the facility was also following recommendations for [CONDITION(S)]-CoV-2 COVID-19 response as provided to them by the State Residential Care Facility (RFC) Comprehensive Mitigation Guidance, dated 11/8/21, with additional guidance from the County Health Department (CHD). C. Failure to perform [CONDITION(S)]-CoV-2 COVID-19 outbreak testing per CDC guidance 1. [CONDITION(S)]-CoV-2 COVID-19 outbreak testing facility observations Licensed practical nurse (LPN) #2 was observed while collecting nasopharyngeal swab specimens for PCR [CONDITION(S)]-CoV-2 COVID-19, during the facility's COVID-19 outbreak. On 11/15/21 at 11:06 a.m., LPN #2 was in the front customer service office performing a PCR COVID-19 nasal swab test on a resident. LPN #2 was not wearing a NIOSH approved N-95 mask. LPN #2 was wearing a surgical mask and face shield, and a protective gown but failed to fully secure the protective gown over her uniform. The door to the testing room was left open during the testing procedure, leaving the individual in the front lobby at risk of exposure to any potentially airborne COVID-19 [CONDITION(S)] droplets expelled during the testing process. Once the testing procedure was complete the sample was secured by LPN #2, and she left the testing area to perform other duties throughout the facility. LPN #2 failed to clean her face shield (a potentially contaminated surface), was wearing potentially contaminated clothing (since no gown was worn during sample collection) and failed to disinfect the testing area before leaving the area unattended. The door remained open and other individuals were able to enter the testing area being at risk of unknowingly coming in contact with potentially contaminated surfaces. On 11/15/21 at 12:07 p.m., LPN #2 reentered the front customer services office to collect [CONDITION(S)]-CoV-2 COVID-19 nasopharyngeal samples from two staff members. LPN #2 was not wearing a NIOSH approved N-95 mask. The two staff were seated in the testing area less than six feet apart while they removed their surgical mask for testing. LPN #2 was wearing a surgical mask and face shield. LPN #2 performed hand hygiene and put on clean gloves, for each staff member tested . She did not wear a protective gown while performing the swab testing to protect her clothing from potential cross contamination while performing the nasopharyngeal testing for either staff member. The door to the testing area was left open during testing or each staff member potentially exposing individuals in the lobby to COVID-19 [CONDITION(S)] droplets during the testing period. The nurse failed to disinfect the face shield she wore after testing staff and prior to leaving the testing area to perform other facility tasks; the nurse also failed to disinfect the testing area and cart after collecting the samples and before leaving the testing area unattended with the door open. On 11/15/21 at 1:04 p.m., LPN #2 was observed entering resident room [ROOM NUMBER] and then room [ROOM NUMBER] to collect a [CONDITION(S)]-CoV-2 COVID-19 PCR specimen from the residents. LPN #2 wore an N-95 mask, face shield, gown and gloves. The gown was not fully secured to cover the nurse's uniform and she failed to disinfect the face shield when leaving one resident's room and before entering another resident's room. 2. Interviews confirmed the facility failed to follow CDC guidance when performing [CONDITION(S)]-CoV-2 COVID-19 outbreak testing. LPN #2 was interviewed on 11/15/21 at 12:20 p.m. LPN #2 said was assigned to perform PCR [CONDITION(S)]-CoV-2 COVID-19 outbreak testing for both residents and staff members. This was the second round of testing to be done in response to the facility's COVID-19 outbreak, which started last week after two staff tested positive for COVID-19. All second round testing samples were to be collected by the end of the day. Staff and most residents were tested in the front customer services office but some residents were tested in their rooms. The IP usually performed the PCR swab testing but LPN #2 was assigned to assist with testing on 11/15/21. LPN #2 said she watched a video on methods for collecting a nasal swab, read a hand out on how to collect a nasopharyngeal swab specimen, she had not reviewed cleaning the testing area, and the IP reviewed what personal PPE to wear. LPN #2 was told to wear a surgical mask, a gown and a face shield when collecting specimens; an N-95 mask was not necessary. LPN#2 touched her surgical mask several times during the interview and did not perform hand hygiene before or after touching the mask. The DON was interviewed on 11/15/21 at 2:21 p.m. The DON said the facility's [CONDITION(S)]-CoV-2 COVID-19 outbreak started when a fully vaccinated CNA who worked the night shift reported to the facility she felt sick. The CNA positive test results were reported on 11/8/21 putting the facility in COVID-19 outbreak status. All nursing staff were then educated on collecting COVID-19 nasopharyngeal samples for PCR testing. The DON said after consulting with the CHD, on 11/8/21, they began outbreak testing twice a week. Testing would continue twice a week until the facility had a full round of negative PCR tests from all staff and residents. The CHD told the facility all staff needed to continue to wear surgical masks and add eye protection while working in the facility until the facility had a round of negative COVID-19 tests then staff can stop wearing the eye protection. The CHD did not say staff were required to wear N-95 masks while working in the facility. The DON provided an email from the CHD, dated 11/12/21, it read in pertinent part: Now that you have identified positives in your facility you will need to begin outbreak testing. Outbreak testing was twice weekly. PCR tests for all staff and residents regardless of vaccination status, as well as daily rapid [MEDICATION(S)] tests for unvaccinated staff and residents. This testing schedule will continue until no new positives are identified. Once you receive a round or all negatives, you move to outbreak exit testing which was once weekly PCR tests for all staff and residents along with the daily rapid [MEDICATION(S)] tests for unvaccinated staff and residents. After three rounds of negative PCR tests your outbreak will be resolved. -The email did not give any guidance on methods of testing. The DON, IP and previous DON (PDON) were interviewed on 11/18/21 at 2:25 p.m. The acknowledged their policies and procedure needed to be revised and updated as they were still following the previous owners policies. The new cooperation had not yet finalized the policy and procedure revisions. The IP said they needed to observe for PPE breaks. They were in the process of educating all nurses again on proper protocols for COVID-19 testing procedures and all nurses were expected to be able to collect a viable specimen while following proper infection control practices to prevent cross contamination and spread of [CONDITION(S)]-CoV-2 COVID-19. After education, each nurse was expected to show competency by return demonstration. Starting on Monday 11/22/21 all staff will be tested in an outside testing site at the facility. The tester will handle the testing kit and instruct and monitor the staff as a nasal pharyngeal swabbed sample was collected assisting only as needed. Each tester will be instructed and expected to wear full PPE with an N-95 mask. The tester will perform hand hygiene prior to performing testing with each staff member; they will apply clean gloves and then remove the gloves and sanitize their hand after testing each person. The testing site will be sanitized every hour and when the area was soiled with the standard FDA approved peroxide solution. The area will be fully sanitizing after the days testing was complete or when there were breaks in testing with an approved sanitizing solution. The same will occur with rapid [MEDICATION(S)] testing. Staff were expected to arrive a few minutes prior to their shift, obtain a testing kit and test themselves outside. All staff required to conduct daily rapid POC testing had been trained on proper technique and procedure. The DON acknowledged return PCR test result turnaround time was not timely and did not know of options to seek available labs who could provide results in a timelier manner so staff were not working while being potentially positive with COVID-19, prior to the outbreak testing result being delivered. It was suggested to the DON and IP they contact the State lab for options. IV. Facility follow-up No additional documentation was provided after the end of the survey.

Based on observations, record review and interviews, the facility failed to ensure that a resident received timely assessment and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review and interviews revealed the facility failed to recognize and effectively assess the resident's continued expression of uncontrolled pain as symptoms of major injuries sustained following a fall in the facility. This failure led to the resident experiencing severe pain for 48-hour delay in treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #109 was admitted to the facility after experiencing a decline in ability and weakness in motor skills and functional ability. The resident obtained a urinary tract infection, which contributed to health declines and ended up requiring emergency room treatment, hospitalization and inpatient rehabilitative therapy on two occasions prior to the resident being admitted to the facility for care. The resident was admitted to the facility on [DATE] due to functional decline and was assessed to need extensive assistance with all activities of daily living (ADL). The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician did increase the resident dose of [MEDICATION(S)] medication to address the resident's muscle spasms and associated muscle pain. The resident's records documented that the resident had an unwitnessed fall on 11/11/21 at approximately 5:30 a.m. When assessed, the resident reported thinking it was time for work and then tried to get out of bed. The resident was found on the floor on hands and knees. The registered nurse assessment of the resident reviewed no visual signs of bodily deformity or other injury. The resident immediately complained of hip pain. An on-call nurse practitioner from the resident physician's office order an immediate single view x-ray of the resident's chest, hips, and pelvic area. Later that same day the resident physician completed a new patient history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . The diagnostic results of the x-ray taken 11/11/21, at the facility after the resident's call revealed no significant findings of cause of resident uncontrolled pain. Over the 48 hours following the resident's fall, the resident continued to complain of severe and uncontrolled pain throughout her body and was frequently unable to describe or pinpoint the exact location of the pain. In addition to routine pain medications ([MEDICATION(S)]) and muscle relaxant medication ([MEDICATION(S)]), the resident was given as needed narcotic pain medication ([MEDICATION(S)]-acetaminophen) and as needed muscle relaxant medication ([MEDICATION(S)]). Despite prescribed medication, the resident continued to experience severe uncontrolled pain. The medical record revealed the resident would sleep following the administration of narcotic medications and resume yelling out and complaining of pain when the medication started to wear off and in the time frame between the resident being able to receive another dose of medication. None of the treating nurses alerted the resident's physician that the resident pain persisted or that pain mediation was ineffective to manage the resident pain. Failure to alert the resident physician or seek additional treatment measures delayed proper diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 11/13/21 at 5:34 a.m., 48 hours after the resident fell , the facility made a determination to send the resident to the emergency room for further assessment of injuries. The resident was assessed and required impatient treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Fall-related injuries included a fractured right elbow, two fractured ribs and a pleural effusion (see hospital findings documented below). Findings include: I. Facility policies and procedures The Fall Prevention Program policy, dated 2021, by the nursing home administrator (NHA) on 11/17/21 at 2:30 p.m. The policy read in pertinent part: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The facility utilizes a standardized risk assessment for determining a resident's fall risk. The risk assessment categorizes residents according to low, moderate, or high risk. For program identification purposes, the facility utilizes high risk and low/moderate risk, using the scoring method designated on the risk assessment. When any resident experiences a fall, the facility will: -Assess the resident. -Complete a post-fall assessment. -Complete an incident report. -Notify physician and family. -Review the resident's care plan and update as indicated. -Document all assessments and actions. -Obtain witness statements in the case of injury. II. Resident #109 A. Resident status Resident #109, under the age of 65, was admitted on [DATE] and was admitted to hospital 11/13/21 According to the November 2021 computerized physicians orders (CPO) diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 11/3/21 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required extensive assistance with a two plus physical assist with bed mobility, transfers and was total dependent on staff to use the toilet. The resident was not steady, and was only able to stabilize with staff assistance; the resident did not walk and used a wheelchair with staff assistance to navigate the environment. Direct care staff did not believe the resident was capable of increased independence. The resident was frequently incontinent of bowel and bladder and was not on a toileting program. The resident was on scheduled and as needed pain medications to treat constant pain the resident described as limiting her daily activities and assessed to be at a level of seven out of 10 (on a scale from zero to 10, with 10 being the severe pain). The resident had experienced falls in the last month and in the past two to six months, the assessor was unable to determine if the resident had any fall-related fractures in the past six months. B. Resident interview Resident #109 was not available for interview and observation, during the investigation, due to being in the hospital and being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #109's representative was interviewed on 11/19/21 at 12:46 p.m. The resident's representative said Resident #109 had been in and out of the hospital twice prior to being admitted to the facility. The representative said the resident had a severe urinary tract infection. She was treated in the hospital and went home, but the resident's condition soon worsened and the resident was unable to stand, walk or transfer herself. Because the cause of the resident's decline was unknown and there was no caregiver in the home, Resident #109 was taken back to the hospital. Diagnostic test revealed the resident still had a [CONDITION(S)]. Resident #109 was sent to the facility for rehabilitation and strengthening with the goal to eventually discharge to an assisted living facility. The representative said the resident was admitted to the isolation unit because she was only partially vaccinated against COVID-19 and needed to be quarantined for 14 days before moving to a room on one of the main units. The resident was very isolated on the unit, reporting that she barely saw the staff and had a hard time getting them to respond to requests for pain relief. The representative said the resident has chronic pain and had difficulty managing the pain at home and when Resident #109 stated to call the representative and complain of unrelieved pain the representative initially thought the resident was waiting until the last minute to request prescribed as needed pain medication and advised the resident to let the nurse know the minute she was feeling pain so that her pain could be better managed. The representative said she received a call on 11/11/21 from the facility nurse explaining that Resident #109 had a fall and the x-rays were negative for fractures. Later that evening (at 7:35 p.m.) the representative received a call from Resident #109 who was screaming in pain and asking for 911 to be called because the staff were not responding for pain relief. The representative said she tried to calm Resident #109 and requested she work with staff for pain management since earlier x-rays were negative for fractures. The next day the representative learned Resident #109 called 911 herself after talking with the representative on 11/11/21, because she felt her pain was not normal. The paramedics arrived but after consultation with the facility staff and the resident's physician, it was deemed unnecessary for Resident #109 to be taken to the hospital. The representative was concerned that the resident had gone days before being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Record review 1. Pre admission paperwork Pre admission paperwork from the hospital, dated 10/21/21, documented Final Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] .Will likely need placement in a skilled nursing facility; physical therapy and occupational therapy. History: Patient was admitted about a month ago with [CONDITION(S)] syndrome as well as generalized weakness . She normally lives alone and has been having a friend help her . She returned to the emergency department today due to the impaired mobility and her friend has been working on trying to get her into a skilled nursing facility, which the patient will require at this time as she failed outpatient management. 2. Baseline care plan The baseline care plan, dated 10/30/21, revealed the resident was a fall risk and had no reported pain. -The baseline care plan identified the resident care needs but failed to identify services and treatments to be administered by the facility and personnel acting on behalf of the facility. 3. Fall assessment The resident was initially assessed to be at moderate risk for falls on the admission fall assessment scale, dated 11/11/21 at 5:55 a.m., but later in the day (11/11/21 at 7:31 p.m.) after a fall that resulted in uncontrolled pain the resident was reassessed on the same fall assessment scale and was found to be at high risk for falls. Predisposing factors included impaired gait: difficulty rising from chair, uses chair arms to get up, bounces to rise; keeps head down when walking, watches the ground; grasps furniture, person or aid when ambulating; and inability to walk unassisted. The resident was overestimating and or forgetting limits. 4. Comprehensive care plan The comprehensive care plan, dated 10/29/21, revised 11/11/21 in pertinent part, the plan documented the following resident care focus needs: Need for care assistance: The resident had an activities of daily living (ADL) self-care performance deficit related to requiring extensive dependent assistance with all ADL's, toileting and bathing. The care plan failed to detail care interventions for each ADL care task (bathing, bed mobility, dressing, eating, oral care, personal hygiene, toilet use, and transfers). Fall risk: Resident had an actual fall 11/11/21, no injuries at this time. Interventions included: -All staff to ensure frequently used items on her bedside stand close to her bed, -Call bell should always be within reach. -Nursing staff will ensure that the bed is lowered to the floor. -Nursing staff will monitor neuro-checks once a shift is ordered. -The care plan failed to document the resident history of falls prior to admission. Pain management: Resident had chronic pain with the goal that pain will be managed to the greatest extent possible so that it did prevent day-to-day activities -The care plan failed to include any intervention for pain management to control a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Medication orders -[MEDICATION(S)] tablet 20 milligram (mg), give 20 mg by mouth three times a day for muscle spasms, start date 11/9/21. Scheduled to be administered at 8:00 a.m., 1:00 p.m. and 8:00 p.m. -[MEDICATION(S)] tablet 600 MG, give 600 mg by mouth three times a day for [CONDITION(S)], start date 10/30/21. Scheduled to be administered at 8:00 a.m., 1:00 p.m. and 8:00 p.m. -[MEDICATION(S)] tablet 0.5 mg, give 0.5 tablet every 8 hours as needed for muscle spasms, start date 11/9/21. -[MEDICATION(S)]-acetaminophen tablet 5-325 mg, give one tablet every 6 hours as needed for moderate pain #3-5 out of 10, start date 10/29/21. -[MEDICATION(S)]-acetaminophen tablet 5-325 mg, give two tablets every 6 hours as needed for moderate pain #6-10 out of 10, start date 10/29/21. -[MEDICATION(S)] Tablet 600 mg, give 600 mg by mouth every 6 hours as needed for mild pain or fever, start date 10/29/21. 6. Progress notes and assessment Administration orders dated 11/11/21 at 5:05 a.m., read in part: [MEDICATION(S)] acetaminophen 5-325 milligrams (mg) two tablets, for pain 6/10 plus .as needed administration for complaints of pain in lower extremities pain rated 8/10. The medication was: Ineffective. Nurse assessment post fall review dated 11/11/21 at 5:50 p.m. documented Resident #109 had an unwitnessed fall in the resident's room. Per the assessment, the resident was engaging in an unassisted transfer from bed and fell forward on her hand and knees. The resident was wearing regular socks. When asked what happened the resident stated she was getting up because she thought she had to go to work. The nurse indicated the resident had recent medication adjustments but was not taking any medication prior to the fall that may have attributed to the resident falling and was not showing signs of mental status change. Upon physical assessment for injuries the resident complained of severe hip pain and was unable to bear weight. -The accuracy of the post fall report was uncertain because the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Which could have accounted for a mental status change and the resident's diminished ability to identify more areas of pain/injury may have warranted further assessment. Nursing note dated 11/11/21 at 5:56 a.m., read in part: Situation - change of condition . evaluation: fall, pain - uncontrolled) . Neurological status: Nursing observations, evaluation, and recommendations are: Resident found with both knees and both hands on the floor her buttocks in air in her room next to her bed. Resident stated she thought she had to go to work. Resident denies hitting her head; however, resident complained of pain to right and left hip upon palpation noted. No noted bruising, contusions, or deformities to extremities. Neurological within normal limits (WNL). Range of motion (ROM) WNL for the resident. Max assistance from staff to get residents into bed. Head non-tender to touch with no noted bruising or contusions. Primary care provider responded with the following feedback: Recommendations: New order received for immediate x-ray to right, left hip and pelvis. Administration orders dated 11/11/21 at 9:39 a.m., read in part: [MEDICATION(S)] acetaminophen 5-325 milligrams (mg) two tablets, for pain 6/10 plus .as needed administration was: Ineffective - resident continues to yell out and states she hurts, x-rays have been completed, awaiting results. Follow-up pain scale was: 7. Administration orders dated 11/11/21 at 12:47 p.m., read in part: [MEDICATION(S)] 0.5 mg tablet . every eight hours as needed for muscle spasms take 0.25 mg - resident having increased muscle spasms causing increased pain as well. Administration orders dated 11/11/21 at 12:47 p.m., read in part: [MEDICATION(S)] acetaminophen 5-325 milligrams (mg) two tablets, for pain 6/10 plus .every six as needed administration for resident having increased pain all over, declines any other interventions offered. Nursing note dated 11/11/21 at 1:51 p.m., read: Resident's physician was in facility today and saw resident, resident told the physician that her hips don't hurt and she does not recall her fall in the early morning today, x-ray results of her hips and pelvis were obtained and reported to physician, chest x-ray faxed to physician's office. Resident told the physician that her right arm hurt. The physician gave a verbal order for a two view x-ray of the resident's right humerus and right forearm due to increased pain. Physician's note dated 11/11/21, read in pertinent part: Date of Encounter: 11/11/2021 Medical Necessity of Visit: New patient visit to establish care. Chief Complaint: This is an admission health and physical on Resident #109. The Patient . presented to the emergency room with an inability to ambulate and two recent falls secondary to [CONDITION(S)] and was unable to maintain her ADLs. She was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospital records show that she was admitted on e month prior with [CONDITION(S)] syndrome as well as generalized weakness and underwent extensive workup that did not demonstrate any repairable pathology. At that time, she was discharged to a rehabilitation facility where she was ultimately discharged back to her apartment only days prior to readmission to hospital as described above. -History of Present Illness: The patient was seen for repeated falls. Patient states she had two recent falls due to weakness prior to her last hospitalization . Nurse informed me that she had another fall this morning where it appeared that she rolled out of bed, which is at a low height. She was found on all fours on the floor. Patient at that time apparently was complaining of severe pelvic pain. X-ray of the pelvis was ordered which showed no acute osseous abnormalities. During the exam today, the patient stated no pelvis pain but was complaining of severe right arm pain. She was unable to locate the pain and stated her whole arm hurt. -Resident #109 is reportedly stable with respect to chronic pain syndrome. Possible alcohol polyneuropathy. Patient was admitted on [MEDICATION(S)] 5/325 one to two tablets every six hours PRN, [MEDICATION(S)] 600 mg q six hours as needed, [MEDICATION(S)], and [MEDICATION(S)] 600 mg. - Musculoskeletal: Decreased strength of upper/ lower extremities. No gross anatomical abnormalities are noted in the right upper extremity but the patient does not allow examination due to complaints of pain. - Assessment and Plan: Repeated falls: With respect to patient's repeated falls - discussed fall prevention with patient. Ordered two view x-rays of right humerus and right forearm. Continue to monitor. Behavior note dated 11/11/21 at 1:54 p.m., read: Resident continued to call out all morning in pain, at lunch time resident told the certified nurse aide (CNA) she was too cold to feed herself and asked for CNA to feed her . continued to yell out in pain, resident stated she was having bad muscle spasms as well, also stated her hips hurt, pain medication and muscle spasm medication given to resident, resident at this time is resting. Administration orders dated 11/11/21 at 7:39 p.m., read in part: [MEDICATION(S)] acetaminophen 5-325 milligrams (mg) two tablets, for pain 6/10 plus .every six hours as needed administration resident requested pain medication for complaints of pain to the right and left hip. Pain related 7/10. Nursing note dated 11/11/21 at 9:17 p.m., read in part: Note Text: At approximately 7:20 p.m., this nurse heard the resident's call light and responded. Resident stated that she was in severe pain to right hip as well as left hip and this nurse administered pain meds [MEDICATION(S)] 5/325 mg at approximately 7:35 p.m. At approximately 8:00 p.m., the ambulance arrived at the facility and told this nurse that the resident had called 911. This nurse briefly explained to the paramedics the resident's medical condition, and that the resident's physician had assessed the resident's situation this morning due to the history of a fall this morning . All x-ray to bilateral hips, pelvis and humerus were performed this morning. All x-ray tests on resident, so far have all come back negative results. The resident decided she should not go to the hospital with paramedics, and is now resting in bed with the pain medication taking effect. Administration orders dated 11/12/21 at 6:00 a.m., read in part: [MEDICATION(S)] 0.5 mg tablet . every eight hours as needed for muscle spasms take 0.25 mg - resident having increased muscle spasms causing increased pain. Administration orders dated 11/12/21 at 6:09 a.m., read in part: [MEDICATION(S)] acetaminophen 5-325 milligrams (mg) two tablets, for pain 6/10 plus .every six hours as needed administration resident requested pain medication for complaints of pain having all over her body. Pain related 8/10. Nursing note dated 11/12/21 at 6:13 a.m., read in part: Resident slept in bed with eyes closed comfortably since yesterday at 8:30 p.m. until 5:50 p.m. this morning. The CNA's entered the resident's room to provide care for the resident. Resident started yelling and hollering aloud. This nurse went into the resident's room asking the resident what was going on. Resident replied in pain. Administered [MEDICATION(S)] 5/325 mg, two 2 tablets at 6:10 a.m. as well as [MEDICATION(S)] 0.5 mg at 6:10 a.m. related to resident having increased muscle spasms causing increased pain noted. Will report to oncoming nurse. Nursing note dated 11/12/21 at 2:58 p.m., read: Resident continues on neurological checks which are at baseline and no increased screaming or yelling this shift and no calls to outside emergency medical assistance. Resident was asleep most of the shift and remains at baseline on her neurological checks related to fall yesterday. Administration orders dated 11/12/21 at 5:46 p.m., read: [MEDICATION(S)] tablet 0.5 mg, give 0.5 mg tablet by mouth every 8 hours as needed for muscle spasms take 0.25 mg. Administration orders dated 11/12/21 at 5:46 p.m., read: [MEDICATION(S)] acetaminophen 5-325 milligrams (mg) two tablets, for pain 6/10 plus .every six hours as needed. Administration orders dated 11/13/21 at 4:32a.m., read: [MEDICATION(S)] acetaminophen 5-325 milligrams (mg) two tablets, for pain 6/10 plus .every six hours as needed administration resident unable to express where pain is, continued yelling out. Nurse note dated 11/13/21 at 5:34 a.m., read in pertinent part: Situation: Change in condition: Resident had altered mental status and pain (uncontrolled). Seems different than usual. Pulse 110 beats per minute . - Neurological status evaluation: Nursing observations, evaluation, the resident was yelling out in pain and was inconsolable, pain medication not effective. Primary care provider notified that the resident was sent to the emergency room for evaluation. Nurse note dated 11/13/21 at 6:00 a.m., read in part: Late Entry: This writer was alerted that Resident #109 woke around 4:00 a.m., yelling out and saying ow, ow, ow but unable to communicate where her pain was. This writer entered the room and the resident continued to yell out and would not respond to questions. She was unable to say where she had pain and when asked to just say yes or no responded to all touch with a grimace. It was noted that she was sweating and was pale in color. She did shake her head yes when asked if she wanted as needed pain medication. Pain medication was administered. A second registered nurse (RN) was asked to assist in the assessment. While trying to identify any areas of concern. The resident repeatedly grabbed her left hip yelling no, staff did attempt an assessment of left lower extremity and to also complete incontinence care but this caused a lot of discomfort and assessment was unable to be fully completed. No bruising or discoloration noted to hip, leg, pelvis or back area. X-rays had been completed of bilateral hips and pelvis, and her shoulder the day before with no findings. This writer and second RN did attempt to calm the resident with low gentle speaking and hand holding for support as well as a cool cloth to wipe her face and neck. This did seem to be effective and the resident was able to settle for a few minutes and drink some water but then continued to yell out. At this time it was determined that the best action was to send the resident out for evaluation. 911 was called and also unable to complete an assessment or vital signs due to the resident's discomfort. Review of the resident's MAR from 10/29/21-11/13/21 revealed the [MEDICATION(S)] order as needed every 6 hours was not administered. D. Post fall hospital report Hospital discharge placement notes emergency department admission to the hospital, admitted d 11/17/21 was reviewed. The report documented: Resident #109 presented to the emergency roiagnom on [DATE] in acute distress. She was disoriented and confused and unable to answer questions. The resident had no obvious signs of injury but appeared to be tender all over. The resident responds to her name but grimaces, moans and calls out ouch through the exam. Initial assessment documented the resident had a liver laceration unrelated to trauma; right elbow injury; and altered mental status. Diagnostic and radiologic results Chest/abdominal/pelvic CAT scan: impression: -Right lung pleural effusions (buildup of fluid), which are partially blocking air flow. No secondary signs of pulmonary hypertension or right heart strain. -Very mild heterogeneity (differences) along the parenchyma (liver tissue) which is nonspecific but could represent grade a mild injury depending on mechanism of the fall. -Subacute (non-displaced crack in the rib) to chronic (untreated, rib fractures will lead to serious short-term consequences such as severe pain when breathing, pneumonia and, rarely, death) left anterior (where the rib attaches to the breastbone) 4th and 5th rib fractures. This patient is being admitted to inpatient status for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This patient cannot be safely treated as an outpatient due to need for urgent consultation. Risks from this illness include respiratory failure. Other injury: Occult (a fracture that is not readily visible, present diagnostic challenges) closed fracture of right elbow, soft cast in place - seen by surgery no surgical intervention needed but will need pain control. Discharge was recommended return to prior facility with skilled level of care. E. Staff interviews The director of nursing (DON) was interviewed on 11/18/21 at 12:30 p.m. The DON said Resident #109 was admitted with a need for skilled nursing services to build strength in her muscles and improve ability to perform ADLs. The resident had several falls while at home. Because the resident was not fully vaccinated, she was quarantined for the first 14 days of admission, but had started rehabilitative therapy in her room. The resident had expressed some loneliness because she was unable to come out of her room and join others in activities and for dining. The DON said on 11/11/21 during 5:00 a.m. rounds, the resident was found on her hand and knees. When asked what happened, the resident said she tried to get up because she thought it was time to go to work. The nurse on duty assessed the resident for injuries, as the staff started to get the resident up off the floor the resident was yelling in pain and grabbing at her hips. The nurse consulted with the physician on call services and x-ray of the resident hips and pelvis were ordered and all came back negative for fractures. The resident's physician was in the facility to assess the resident and thought the resident complaints of pain were related to behavioral factors impacted by being in isolation and if she were moved to a regular resident unit where she could participate in offered activities she would feel better. The resident was moved out of isolation and to a unit where other residents resided. The resident was provided as needed narcotic pain medication and would sleep after administration of the medication but would wake up screaming in pain and was inconsolable; the prescribed pain medication was ineffective. Two midnights later the resident was sent to the hospital for further assessment because she could not stop screaming out in pain and could not be consoled. The physician was notified of that decision. The DON said the RN was expected to conduct a head-to toe assessment after a fall. If there were no malformation of the resident bone structure and there were no concerns with the resident's ability for range of motion, the nursing staff would notify the physician of the findings and continue to monitor the resident for possible changes in condition. The nurse was expected to notify the physician of new and developing changes in condition including signs of shock; internal bleeding; new and developing pain: and signs of pain upon palpation or body area. CNA #8 was interviewed on 11/18/21 at 1:02 p.m. CNA #8 said she worked the overnight shift on 11/12/21. Resident #109 was agitated all night and was yelling out at the beginning of the shift and the nurse got her settled with pain medication then she slept. On the last rounds at approximately 4:00 a.m. Resident #109 started to holler out in pain. Resident #109 was having more pain when she admitted her demeanor had changed because of the pain. RN #1 was interviewed on 11/18/21 at 1:49 p.m. RN #1 said she assessed the resident after her fall on 11/11/21. At approximately 5:30 a.m., the resident was found on the floor on her hands and knees. The resident kept screaming I fell , I need help! A pillow was placed under the resident's abdomen to make her comfortable while being assessed, the resident was on the floor for 30 minutes before being assessed before moving her off the floor. The resident was having a hard time explaining what happened and answering questions about her pain. The resident had no abdominal pain but kept grabbing at both hips and kept screaming of pain and pleading for staff to not leave her alone. After conducting a head to toe assessment, the CNA assisted to get the resident back into bed; the resident was not able to bear weight. RN #1 said she conducted an additional assessment with the resident in bed and the resident was at baseline with range of motion ability, but in a lot of pain. The RN notified the resident's physician on call services and a series of x-rays were ordered. The resident did calm initially after the administration of narcotic pain medication, but continued to experience pain throughout the day. RN #1 said later that evening around 7:30 p.m., the resident called 911 reporting severe pain. The paramedics arrived, and RN #1 explained the resident had x-rays of both hips, her chest, and arm earlier in the day and the physician had also assessed the resident that afternoon after the fall. The paramedics did not take the resident to the hospital after seeing the results of the x-rays. The RN said she thought the resident should have gone to the emergency room because of her pain and was not sure why the resident changed her mind about wanting to go to the emergency room . The RN did not alert the physician of the resident or the resident

Based on observations, record review and interviews, the facility failed to ensure one (#50) of one out of 32 sample residents received care consistent with professional standards of practice, to prevent the development of pressure ulcers, and to promote healing of pressure injuries. The facility's failure to provide necessary interventions to prevent Resident #50 from developing pressure ulcers, promote healing of the pressure ulcers and prevent worsening of the pressure ulcers. The resident was a significant risk for the development of pressure ulcers based on her compromised health, being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Due to the facility's failures, the resident developed a facility acquired unstageable pressure ulcer to the sacrum at the lower end of the spine (diagnosed [DATE]), and facility acquired right heel stage 3 pressure ulcer (duration 9/9/2020). Furthermore, the nurse failed to follow the physician's wound care orders during the observed wound care. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel (NPIAP) Stages, last updated 2016, retrieved on 11/23/21 from: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf revealed the following pertinent information: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin . Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis . Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.`` II. Facility policy and procedure The Wound Care policy and procedure was requested from the nursing home administrator on 11/18/21 at 11:50 a.m. However, it was not provided during or after the survey. III. Resident #50 A. Resident status Resident #50, age 66, was initially admitted on [DATE]. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/24/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance with two persons for bed mobility, transfers, dressing, bathing, and toilet use. Supervision and one person assistance required for personal hygiene. She reported symptoms of feeling tired or having little energy several days per week. No behaviors or rejection of care. Per the MDS the resident had no pressure ulcers upon admission. She was at risk for the development of pressure ulcers and had one or more unhealed pressure ulcers/injuries at the time of this assessment. The resident had one unstageable pressure ulcer due to coverage of the wound bed by slough and/or eschar. B. Resident observations (cross-reference F880 for infection control measures) LPN #1 was observed on 11/17/21 at 10:11 a.m. as she performed Resident #50's wound care. The resident was lying flat on her back in bed putting pressure directly on the lower back and sacral wound. (per the resident's care plan the residents was to be positioned to offload pressure risk areas ). There was a low air loss mattress on the bed however, during the physician interview (see below, the wound doctor said the resident would benefit from a different mattress, an alternating air mattress). LPN #1 entered the room to complete the resident's wound care. The right foot gauze was stuck on foot wound, the date was not readable on the tape, LPN #1 continued the treatment with soiled gloves. The size of the right heel wound was approximately 3.3 cm length x 3.3 cm width (approximately half a dollar size) with black eschar and slough present around the wound. LPN #1 cleaned wounds with wound cleaner, and used the same gloves to apply the [MEDICATION(S)] treatment which she squirted on the wound. Then LPN #1 wrapped up the ankle with gauze. LPN #1 helped Resident #50 roll to the left side. The resident lower back at the sacral area had a wound approximately 4 cm length x 7.5 cm width (larger than a deck of cards), black in color, bleeding and red, it had an odor. It had an unlabeled gauze just below brief. There was a lot of eschar around this wound. LPN #1 said the nurses change the sacral dressing as needed, approximately once per day. LPN #1 said the treatment was to clean it and apply gauze. She took off gloves to get tape out and wrote date and time and initials on the tape. LPN #1 assisted Resident #50 to roll to the right side. LPN #1 looked at the left hip/buttocks and said it looked like there was a soiled dressing left inside the wound bed of the left buttocks area with gauze stuck in it. LPN #1 cut a new gauze with scissors and stuffed it into the wound on the left hip/buttocks area. -LPN #1 failed to follow the wound care orders during the observed wound care as described above. LPN #1 did not follow the prescribed order for the left buttock wound, by not cleaning the wound, patting dry, inserting calcium alginate, or wrapping with conventional dry dressing. -The lack of nursing hand hygiene and sanitary practices with wound care treatment potentially contributed to the sacral wound infection (see wound doctor interview) and put the right heel wound at risk for infection. Cross-reference F880 failed to provide wound care in a manner to prevent potential cross contamination of infectious matter. -Resident #50 was cooperative throughout wound care treatment with no refusals of care or positioning. C. Record review The initial admission nursing assessment dated [DATE] revealed the Resident #50 had no skin issue on the right heel or the sacral area. The only skin issues present on admission: top left foot injury from fall at home during a transfer; right inner ankle dry skin; left inner ankle dry skin. The 11/5//21 Braden scale for predicting pressure sore risk revealed the resident was at moderate risk of developing a pressure sore. Risk factors included the following impairments: The resident was very limited in ability to respond meaningfully to pressure-related discomfort. The resident was only able to respond to painful stimuli and/or could not communicate discomfort except by moaning or restlessness or had a sensory impairment which limits the ability to feel pain or discomfort over half of her body. The resident's skin was occasionally moist, requiring an extra linen change approximately once a day. Ability to respond meaningfully to pressure-related discomfort was very limited. The resident's ability to walk was non-existent, she could not stand on her own weight and/or must be assisted into a chair or wheelchair. Mobility was very limited and the resident was not able to make slight changes in body positioning independently. The resident's usual food intake pattern was inadequate and she rarely ate a complete meal. The resident's exposure to friction and shear was a potential problem because movement can cause friction against the skin causing impaired skin integrity. Resident #50 admitted to hospice care 10/22/21 due to [CONDITION(S)] related to urinary tract infection. On 11/18/21 at 8:55 a.m, during the wound care doctors rounds, the DON said hospice agreed to allow wound care oversight by the weekly physician wound care rounds. The 11/11/21 wound care note revealed the following. -Right heel, diagnosed [DATE], stage III pressure injury/ulcer, not healed. -Left buttocks, diagnosed [DATE], status post [MEDICAL RECORD OR PHYSICIAN ORDER] -Sacrum, diagnosed [DATE], unstageable pressure injury/ulcer, not healed. Resident #50 was seen at the hospital 11/15/21 due to altered mental status, [CONDITION(S)] related to urinary tract infection. The 11/15/21 after hospital visit summary report revealed the resident was admitted with the following wounds: -Pressure injury of skin, unspecified injury state, unspecified location. -Stage 3 pressure ulcer of buttock. -Skin ulcer of sacrum, unspecified ulcer stage. -Skin ulcer of heel with fat layer exposed, unspecified laterality. The resident returned from the hospital on 11/15/21. The comprehensive care plan for skin integrity initiated 3/6/16 and last revised 11/14/21, revealed the resident had potential impairment to skin integrity. Interventions included avoidance of scratching, keep hands and body parts from excessive moisture, and keep fingernails short. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Encourage resident to change positions/turn and reposition frequently to offload pressure risk areas. She was on a repositioning program, revision 10/1/21. Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident educated on the risks of not repositioning and maintaining her weight, revision 10/1/21. Skin prevention treatments per order. Treatment to the right heel per physician orders. Wound nurse to evaluate weekly. Wound doctor to see resident weekly. Weekly skin checks by nurse, document findings. The computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Wound care, per wound doctor (WD), to the right lateral foot, apply sure prep, one time per day, every other day. Start date 11/6/21. -Wound care, right heel, cleanse with wound cleaner, pat dry, apply medi honey to wound bed on ankle and heel, cover with army battle dressing (ABD), wrap with kerlix one time per day, every other day. Start date 8/9/21. -Cleanse surgical pocket to left buttock with normal saline (NS) pat dry. Insert calcium alginate gently, pack the pocket and cover with conventional dry dressing (CDD) one time per day. Start date 11/5/21. -Cleanse area to the left and right ischium, pat dry and apply sure prep one time a day for skin integrity. Start date 10/7/21. -Apply sure prep to sacral area for skin integrity two times a day for skin integrity. Start date 6/4/2020. -Cleanse area to sacrum, pat dry. Apply [MEDICATION(S)] (may substitute Dakins until [MEDICATION(S)] arrives) to the sacral area, then cover with ABD one time per day. Start date 11/20/21. On 11/17/21 at 10:11 a.m LPN #1 failed to follow the wound care orders during the observed wound care as described above. LPN #1 did not follow the prescribed order for the left buttocks wound, by not cleaning the wound, patting dry, inserting calcium alginate, or wrapping with conventional dry dressing. Cross reference to F880 for lack of infection control measures. The 11/9/21 nurse note documented: It was reported to this nurse that the resident has a new open area to her coccyx, the site was semi-dry around the edges and slightly dry to the center did have some very minimal moisture to the site. The edges of the site have some rolling and are dry. The site measures (6.3 x 3.0 centimeter (cm)) this nurse did note red [CONDITION(S)] around the site with purplish/reddish coloring to the center of the site. The resident denied any associated pain or discomfort to the site, she was unaware she even had the site to the back. Resident voiced she did not feel that. This nurse will update the residents power of attorney (POA) who was also her daughter, the attending nurse practitioner has also been updated. The site has been cleaned and dressed, a treatment order to be completed. The wound doctor (WD) will follow up and assess the site in rounds. The 11/11/21 registered nurse (RN) skin/wound note documented: Resident was seen today at the bedside for wound rounds with the WD. The area to her right dorsal foot has decreased in size and improved quality. A small area of fibrous tissue noted no drainage or odors noted no signs/symptoms of infection. Peri wound was healthy. Pressure to the right heel was decreased in size with healthy tissue to the wound bed. Minimal amount of drainage with a callous noted to the peri wound. The surgical wound to her left buttock was decreased in size and depth, moderate serous drainage noted periwound was healthy, no maceration or denuded areas noted. A new area of pressure was noted to resident's sacrum, 50 percent eschar noted to wound bed and a reddened periwound scant drainage noted. Treatments are in place resident continues with the use of a LAL mattress and was offered to turn frequently which she will agree to but then will remove any propping pillows and roll onto her back shortly after being repositioned. WD did note that skin failure was unavoidable at this time related to immobility, incontinence, uncooperative with movement and malnourishment despite staff efforts. Dietary will be consulted for further recommendation, resident does have a history with self sabotaging the progress of her wounds and her own personal health. The resident will continue on wound rounds at this time. -Review of the resident medical record and progress notes between 9/1/21 and 11/17/21, failed to reveal documentation of the resident refusing repositioning. The MDS documented that Resident #50 had no behaviors or rejection of care and required extensive assistance from two staff persons for bed mobility, and transfers. Physician wound care notes service date 11/18/21 read in part: Patient assessment and chronicle contributing conditions. Assessment: Healing is expected to delayed (sic) due to the identified factors and inevitable effects of aging. Physician wound care notes service date 11/18/21 read in part: Wound assessment: -Right dorsal foot, diagnosed [DATE]: Etiology: trauma. Measurement:1.2 centimeters (cm) x 0.6 cm x UTD (unable to determine depth). Prior dimension 0.7 (cm) x 0.5 cm x 0 cm. Scab 100%. No drainage. Progress: Stable. Treatment: sure prep, and cover with absorbent sterile gauze. -Right heel, diagnosed [DATE]: Etiology: pressure stage 3. Measurement: 2.3 cm x 3.2 cm x UTD. Prior dimensions: 3.3 cm x3.3 cm x UTD with 30% granulation (important component in the wound healing process) , 70% eschar (a dry, dark scab of dead skin), Drainage: scant. Periwound: callous. Progress: better. Treatment: [MEDICATION(S)], and cover with absorbent sterile gauze. -Left buttock, diagnosed [DATE]: Etiology: surgical. Measurement: 0.5 cm x 5.3 cm x 1.0 cm. Prior dimensions: 1.0 cm x 3.5 cm x 1.0 cm. 100% granulation, Drainage: moderate (serum) Periwound. Progress: stable. Treatment: calcium alginate dressing. -Sacrum (lower spine) unstageable pressure wound, diagnosed [DATE]: Etiology-pressure. Measurement: 9.5 cm x 1.0 cm x UTD. Prior dimensions: 4.0 cm x 7.5 cm x UTD. 90% eschar, 10 % epithelial (thin tissue that lines the outer surface) with tunneling. Drainage: seropurulent Periwound:. Progress: worse. Treatment sure prep and cover with absorbent sterile gauze. -Mid back, diagnosed [DATE]: Etiology deep tissue wound. Measurement: 4.0 cm x 13 cm x 0 cm. 100% epithelialization (the rebuilding of skin cells. Periwound No drainage. Treatment: SP QD. D. Staff interviews The wound doctor (WD) was interviewed on 11/18/21 at 8:49 a.m. with the DON present. The WD said he observed the resident's wounds this morning and had treated Resident #50 one time per week for over one year. He said he made recommendations and changes for the resident's wound care throughout that time and expected the nurses to perform the daily wound care per his orders. He said he relied on the nurses to alert him of any new problems. He said the sacral wound had gotten worse when he saw it 11/18/21. The WD said he would consider the sacral wound infected based on the drainage. The WD said he considered the sacral wound to be a pressure ulcer and not a Kennedy ulcer as the DON put forward during wound rounds with the WD. The WD said the marks on the resident's back were new and that she would benefit from a different mattress. The DON said the resident was provided an air mattress by the hospice provider but that they could change it to an alternating air mattress. The DON said she instructed the CNAs on incontinence care and expected the CNA to change the resident as often as she tolerates. The WD said the wound care treatment order for the wound on the resident's left buttocks was to apply calcium alginate to the wound. The DON and the WD were informed that during the wound care observation on 11/17/21 the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, staff and resident interviews and record review, the facility failed to ensure one (#13) resident requiring respiratory care, including [MEDICAL CONDITION] care and tracheal suctioning, would be provided such care in a manner consistent with standards of practice. Resident #13 was admitted to the facility with a [MEDICAL CONDITION] (trach) to address impaired breathing mechanics. Although the resident wished to, and had since admission on 12/12/18, independently managed [MEDICAL CONDITION] and suctioning, her ability to do so safely and effectively had not been assessed by qualified staff at the facility. Moreover, staff were unprepared to assume these tasks should the resident become unable to complete them. Specifically, interviews revealed direct care staff lacked knowledge, training, and equipment to manage the resident's routine and [MEDICAL CONDITION] needs. The facility's failure to assess Resident #13's ability to provide [MEDICAL CONDITIONS], coupled with staff's lack of knowledge, training and equipment to manage Resident #13'[MEDICAL CONDITION] and suctioning made serious harm likely to occur if the resident experienced acute respiratory distress due to an occluded airway and immediate steps to correct the situation were not taken. Cross-reference F880 infection control and F838 facility assessment. Findings include: I. Immediate jeopardy A. Findings of Immediate Jeopardy Resident #13 was admitted to the facility with a [MEDICAL CONDITION] (trach) to address impaired breathing mechanics. Although the resident wished to, and had since admission on 12/12/18, independently managed [MEDICAL CONDITION] and suctioning, her ability to do so safely and effectively had not been assessed by qualified staff at the facility. Moreover, staff were unprepared to assume these tasks should the resident become unable to do so. Specifically, interviews revealed direct care staff lacked knowledge, training, and equipment to manage the resident's routine and [MEDICAL CONDITION] needs. The facility's failure to assess Resident #13's ability to provide [MEDICAL CONDITIONS], coupled with staff's lack of knowledge, training and equipment to manage Resident #13'[MEDICAL CONDITION] and suctioning made serious harm likely to occur if the resident experienced acute respiratory distress due to an occluded airway and immediate steps to correct the situation were not taken. B. Facility notice of Immediate Jeopardy On 5/16/2019 at 5:21p.m., facility staff, including the nursing home administrator (NHA) and the director of nursing (DON) were informed of the findings of Immediate Jeopardy under F695, respiratory care and services. On 5/17/19 at 9:25 a.m. the NHA provided the following plan to remove Immediate Jeopardy. The plan read: How corrective action will be completed for residents identified as affected by the deficiency: -On 5/16/2019 the identified resident's nurse received immediate competency training on how to provide [MEDICAL CONDITION]. Training is being provided by Respiratory Therapist (RT). -On 5/16/19 RT did a [MEDICAL CONDITION] return demonstration to patient to ensure the patient is safely able to provide suctioning, maintain a clean technique, proper gloving, and how to properly utilize the supplies. -On 5/16/2019 additional supplies of the inner canula (sic), passymuir [MEDICAL CONDITION] valve, and suction kit was delivered to the facility by the RT. -On 5/16/2019 emergency equipment has been placed in identified resident's room and education to resident's nurses has been provided regarding emergency equipment location and use. -On 5/16/19 RT provided facility with a written plan of care for patient. Staff Development Coordinator/designee will provide education prior to start of shift for all nurses providing care to resident. All nurses, facility wide, prior to direct patient care will receive competency training [MEDICAL CONDITION]. -Identified resident was moved to a private room allowing for a better storage and setup [MEDICAL CONDITION]. -RT educated nursing staff in an emergent situation to call 911, maintain airway using [MEDICAL CONDITION] in the room by removal of mucus plug, use of saline to clear airway, and suctioning. Identification of others affected the failure: -No other resident is affected by the failure. Systemic Changes: -RT has trained DON/SDC (Director of Nurses/Staff Development Coordinator) and will continue monthly return demonstration competency validation. As long as we have [MEDICAL CONDITION], DON/RT will validate with all licensed nurses once a [MEDICAL CONDITION] competency. -Director of Nursing/designee will communicate with RT weekly to ensure involvement in the assessment [MEDICAL CONDITION] needs. -SDC/designee will train all new employees prior to direct patient care [MEDICAL CONDITION] including storage supplies and location of emergency trach. -Respiratory Therapist is to reassess and train resident monthly and PRN for ability to [MEDICAL CONDITION] and suctioning. Respiratory to perform a patient assessment [MEDICAL CONDITION] check weekly. -DON/designee will observe resident's [MEDICAL CONDITION] technique twice a week. -Facility placed an order on the MARs (medication administration records) to make sure the emergency equipment is in room and all components included, on every shift. There is an order to change all of the tubing every Sunday. A nursing measure order will be placed for the DON, primary designee and SDC, secondary designee, to ensure equipment and supplies are available and will be responsible for ordering supplies and equipment. DON, primary designee and SDC, secondary designee, will [MEDICAL CONDITION]'s supplies Monday, Wednesday, and Friday. Monitoring: -The review of systemic changes and performance related to [MEDICAL CONDITION] will be presented at monthly QAPI (Quality Assurance Performance Improvement) meetings by NHA/designee for three months then quarterly thereafter. D. Removal of Immediate Jeopardy The facility's plan to remove Immediate Jeopardy was accepted and Immediate Jeopardy was lifted on 5/17/19 at 9:25 a.m. Record review, interview and observations revealed the facility had obtained orders for Resident #13'[MEDICAL CONDITION] and services, Resident #13 had been assessed by the respiratory therapist (RT) for her ability to perform [MEDICAL CONDITION] and suctioning in a safe, sanitary and effective manner, and staff were continuing to receive training [MEDICAL CONDITION] and management.[MEDICAL CONDITION] and emergency equipment were in place and a process had been developed to ensure supplies and equipment were maintained. However, deficient practice remained at a D level, potential for more than minimal harm that is isolated. II. Failure to ensure Resident #13 would be provided respiratory care, including [MEDICAL CONDITION] care and tracheal suctioning, in a manner consistent with standards of practice. A. [MEDICAL CONDITION] care and facility expectations 1. Professional reference According to American Nurse Today (2011) [MEDICAL CONDITION] care: An evidence-based guide, retrieved from https://www.americannursetoday.com/[MEDICAL CONDITION]-care-an-evidence-based-guide-to-suctioning-and-changes/ [MEDICAL CONDITION] care and tracheal suctioning are high-risk procedures. Individuals with trachs are at high risk for airway obstruction, impaired ventilation, and infection as well as other lethal complications. 2. Facility policy and procedure The facility [MEDICAL CONDITION] management policy, released (MONTH) (YEAR), documented, in pertinent part: - There is a licensed nurse with additional training on [MEDICAL CONDITION] care and management on schedule at all times. - Items for emergency [MEDICAL CONDITION] care must be kept at the bedside at all times. Items include ambu bag with mask, suction machine/set up, replaceable [MEDICAL CONDITION], [MEDICATION NAME] suction tip, 10cc syringe, water soluble lubricant and e-cylinder. - The emergency cart or emergency supplies are within reasonable distance. - Staff with direct care responsibilities have undergone training in [MEDICAL CONDITION] care and management of the resident with the [MEDICAL CONDITION]. B. Resident #13 1. Resident status Resident #13, under the age of 65, admitted to the facility on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 3/21/19 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She reported feeling down or depressed two to six days, had trouble sleeping 12-14 days, felt tired 12-14 days, felt bad about herself 12-14 days, had trouble concentrating on things, and had thoughts she would be better off dead or hurting herself seven to 11 days during the review period. She required supervision with all activities of daily living (ADL). She received oxygen, suctioning, and [MEDICAL CONDITION] care. 2. Record review Orders: Review of the computerized physician orders [REDACTED]. Although the resident, following a hospitalization [DATE] for [MEDICAL CONDITION], had received discharge instruction to have the facility place humidification on the resident's oxygen and to use a nebulizer every 2-4 hours, there were no orders for either treatment. Moreover, there were no orders regarding the resident'[MEDICAL CONDITIONS] and suctioning. Care plan: Review of the care plan, initiated on 12/12/18 with a target date of 6/22/19 (there was no current review date), documented the resident had a [MEDICAL CONDITION] related to impaired breathing mechanics. -The goal was for the resident to have clear and equal breath sounds bilaterally through the review date. -The interventions included ensure [MEDICAL CONDITION] are secured at all times, observe/document for restlessness, agitation, confusion, increased heart rate ([MEDICAL CONDITION], and [MEDICAL CONDITION] (slow heart rate), observe/document level of consciousness, mental status, and lethargy as needed, observe/document respiratory rate, depth and quality and check and document q (every) shift/as ordered, provide good oral care daily, provide means of communication and procedural information and reassure that help is available immediately and suction as necessary. -The care plan failed to address the care and management of the resident's trach, including information on the equipment needed for routine and emergency care. C. Failure to ensure Resident #13 would be provided respiratory care, including [MEDICAL CONDITION] care and tracheal suctioning, consistent with standards of practice. 1. Resident interview and observations Resident interview revealed the resident completed [MEDICAL CONDITIONS] daily by herself. Observations and interview revealed a lack of attention to the resident's respiratory equipment needs as well as infection control to minimize the risk of respiratory complications. Resident #13 was interviewed on 5/16/19 at 11:15 a.m. while sitting on her bed in her room. Her suctioning machine was on her nightstand next to her oxygen machine and her oxygen canister was on the ground. The mask, which was attached to the humidifier and used to cover [MEDICAL CONDITION], was on the ground as was the tip of the tube which ran from her suctioning machine and attached to her trach. All of these items were undated. The canister attached to her suctioning machine contained approximately 1 to 1.5 inches of sputum. The resident said staff never change any of this equipment and have not provided her any type of anti-bacterial wipe to keep things clean. No gloves observed in the room. Three boxes [MEDICAL CONDITION] rested on the floor near the head of the resident's bed. Six boxes rested on the floor at the end of her bed with [MEDICAL CONDITION]. The resident said she has always done her own suctioning and has always kept track of her own supplies. She said she was particularly worried because she only had one inner cannula left for suctioning and she used one every day. She said she gets scared some days because she is not sure if the staff have received any training about her [MEDICAL CONDITION]. Resident #13 was interviewed again at 5/16/19 at 3:05 p.m. At this time, observations revealed all of [MEDICAL CONDITION] (tubing, suction canister, and bag with tubing in it), previously undated, now was dated 5/16/19. The resident said this is the first time since admission (12/12/18) that any equipment had been dated. 2. Staff interviews and observations Staff interviews revealed staff were unprepared to assume Resident #13'[MEDICAL CONDITION] and suctioning should the resident become unable to do these tasks herself. Specifically, interviews and observations revealed direct care staff lacked knowledge, training, and equipment to manage the resident's routine and [MEDICAL CONDITION] needs. Moreover, although Resident #13 had been admitted mid-December, (YEAR), her ability to safely and effectively complete her [MEDICAL CONDITIONS] had not been assessed by qualified staff at the facility. a. Licensed practical nurse (LPN) #1 was interviewed on 5/16/19 at 1:20 p.m. She said the only training she had ever received on [MEDICAL CONDITION] care was in school; she said she had never received any such training at the facility. She said she would periodically help the resident with suctioning if the resident asked her to, but usually it was just to help the resident get her equipment in her room if she could not reach it. She said usually the resident takes care of her own suctioning. She said the respiratory therapist comes every Monday to drop off supplies. She confirmed there was no assessment of the resident's ability to perform her [MEDICAL CONDITION] and suctioning in the resident's medical record. She said it made sense to have such an assessment because no one was sure the resident was using the proper technique and she could injure herself. She was unsure who would complete such an assessment and thought it might be a registered nurse (RN). b. The director of nursing (DON) was interviewed on 5/16/19 at 2:30 p.m. in the resident's room, again at 3:11 p.m. to 3:20 p.m. and finally at 3:30 p.m. after reviewing Resident #13's records. The DON observed the canister attached to the suction machine which contained approximately 1 to 1.5 inches of sputum. She said the suctioning device should be changed any time suctioning had occurred. She said that if the oxygen mask or the tubing had been on the floor they should also be changed. She said this was all to control infection. The DON further said she thought there should be an assessment, quarterly and as needed, to ensure the resident's ability to safely manage [MEDICAL CONDITION] and suctioning. She said she was not sure if the resident admitted to the facility completing all of her [MEDICAL CONDITION] but believed so. The DON said the resident's supplies needed to be organized and there needed to be an order so staff could monitor the supplies. Additionally, she said staff needed to monitor the resident's secretions and if the resident had any respiratory difficulties. She said the RT, who came every Monday, did not document on Resident #13's respiratory status when he was in facility but would start now. The DON said review of the resident's records revealed only assessments by the speech therapist to evaluate the resident's speech, communication and swallowing to manage secretions. She also stated there had been no facility training [MEDICAL CONDITION]. She was going to call the speech therapist back into building to complete safety evaluation. The DON said she would look in the supply room to determine if there were more inner cannulas for the resident to use. The DON returned at approximately 3:20 p.m. and said they had approximately ten boxes of inner cannulas in stock but they were the wrong size. She said she would contact the RT and have him return to the building with the correct inner cannula. c. LPN #3 who was very familiar with the resident was interviewed on 5/16/19 at 3:19 p.m. She said, in the past, they had another RT who would visit with the resident and set up equipment. She said that he would usually give staff an invoice but never a clinical note. d. Registered nurse (RN) #3, who routinely cared for the resident and who had cared for her when she was first admitted , was interviewed on 5/16/19 at 4:10 p.m. RN #3 said she had received education on a [MEDICAL CONDITION] while she was in school but had never received such training at the facility. She entered the resident's room and attempted to look for the emergency kit for the [MEDICAL CONDITION]. She said she did not know where it was and asked the resident. The resident pointed to the closet. Upon opening the closet, RN #3 retrieved a box which had the [MEDICAL CONDITION] inside. The resident said here is something they wanted me to have and provided the facility [MEDICAL CONDITION] policy which listed seven emergency items that should be available in the resident's room. RN #3 confirmed there were missing equipment in the room in case of a respiratory emergency specifically, there was neither an Ambu bag nor 10 cc syringe were in the resident's room. RN #3 agreed it would be difficult to ask the resident where the emergency supplies were in the room if the resident could not breathe. She also said that she would not feel comfortable if she needed to replace the resident'[MEDICAL CONDITION] said she would call for a nurse manager. She said if she had been trained, she would feel more comfortable. She agreed that when she entered the resident's room she did not know where the emergency supplies were and would need to rely on the resident to tell her. She said this would not be the best practice. RN #3 was interviewed again on 5/22/19 at 4:00 p.m. She confirmed she had received [MEDICAL CONDITION] and felt much more confident in her abilities if something would happen to the resident. e. The DON and RN #3 were interviewed again at 4:20 p.m. The RN said all seven of the emergency items listed in the [MEDICAL CONDITION] policy were on the crash cart; therefore, staff could use the crash cart if there was an emergency. The DON said that even though the crash cart was up the hall from the resident's room, if one of my nurses yells for help, we are fast (and could get to the room quickly). The contents of the three crash carts in the facility were examined to determine if the emergency items were available. Each crash cart was missing the 10 cc syringe. (Information submitted by the facility after exit revealed 10 cc syringes are not supplies the facility maintains or is expected to maintain in the crash carts.) 3. Respiratory therapist (RT) interview The RT #1 and RT #2 were interviewed on 5/17/19 at 11:27 a.m. regarding RT procedures prior to survey. RT #1 said his responsibilities included ensuring that RT #2 received clinical training and assisting the facility staff with any clinical questions they may have. RT #2 said his responsibilities included checking on residents that receive the company's services, see residents that have [MEDICAL CONDITIONS] and meet with residents to ensure they have what they need. He confirmed he had not completed clinical notes on the residents he met with that had a trach. D. Facility action after Immediate Jeopardy called on 5/16/19 at 5:21 p.m. 1. Record review a. Completion of Resident #13's respiratory assessment and training The 5/16/19 progress note completed by the RT documented the following: - Resident was trained on how to properly [MEDICAL CONDITION] and suctioning. - After resident was trained she did a return demonstration. - Resident can perform self-trach care and suctioning while using a mirror and showed she can be sterile with suctioning and aseptic with track care. - Resident state she was comfortable [MEDICAL CONDITION] and suctioning on her own with little to no assistance. Recommendations included: -[MEDICAL CONDITION] daily and PRN (as needed) using aseptic technique; - Suctioning PRN using sterile technique; - [MEDICAL CONDITION] when gets wet and PRN; - Change inner cannula daily and PRN; - Nursing to assist resident as needed; - RT to visit weekly and PRN to assess resident and check supplies. b. Completion of staff training on 5/16/19: RT #1: -Suctioning, don sterile gloves clean hand dirty hand use dominant hand for cath. Non-reusable one time only. -[MEDICAL CONDITION] care aseptic, ensure you have all your supplies prior to starting set-up field, don sterile gloves, saturate 4x4, work from inside out. Tip flange wipe out new clean area of 4x4 for each wipe, assess stoma area, change neck tie each time it is wet and back of neck. If [MEDICAL CONDITION] to come out or need to be bag ventilation a [MEDICAL CONDITION] need to be inserted then bagged, needs to be cuffed to bag. Staff development manager (SDM) and the MDS Coordinator (MDSC): -Location and set up of [MEDICAL CONDITION] Supplies - Physical demonstration of supply set up and use. If we move rooms the new room needs to be set up the same as old room. CNA education included where the emergency kit is in room, extra supplies on crash carts, crash cart locations, if there is an emergency do not leave resident alone - yell for help. Training completed by SDM: -RT recommendations and evaluation of resident regarding [MEDICAL CONDITION] management for this resident. -[MEDICAL CONDITION] care/management based on the [MEDICAL CONDITION] Management policy, the Spontaneous Decannulation: Reinsertion of [MEDICAL CONDITION] Tuby and the Passy Muir [MEDICAL CONDITION] Valve c. Orders Review of Resident #13's orders revealed orders to: - Monitor every shift for frequency of suctioning completed by resident every shift, start date 5/16/19. - Monitor [MEDICAL CONDITION] three times per week to ensure adequate supplies available every day shift every Monday, Wednesday and Friday; order date 5/17/19 and start date 5/20/19. 2. Interviews 1. RT #1 and #2 The RT #1 and RT #2, during their interview on 5/17/19 at 11:27 a.m., explained the changes in RT responsibilities and procedures since 5/16/19. RT #2 said moving forward, the DON or unit manager (UM) would sign for [MEDICAL CONDITION] he delivers. RT #2 said, in addition, he will complete a respiratory assessment weekly that will include listening to breath sounds, checking oxygen levels, and possibly [MEDICAL CONDITION] to keep eye on stoma, as well as anything else respiratory-related. He also will check on the stock of supplies. He said he would want to see if there had been any changes from the previous week. RT #2 said on a monthly basis, he would follow up with the resident and provide reeducation and retraining, [MEDICAL CONDITION] stoma care and would observe the resident if there had been a change of mental status. He said he would identify whether the resident needed to be reevaluated sooner and then notify the facility. Both RT #1 and RT #2 said a clinical note would be written weekly and it would be given to the DON. RT #2 said that it would benefit the resident to have a clinical RT looking at the resident'[MEDICAL CONDITION] with the nursing staff. 2. Regional clinical director (RCD) The RCD was interviewed on 5/17/19 at 6:57 a.m. He said they had moved the resident to a private that had a larger closet for all of her supplies. He said when he entered the facility the night before he saw all of the failures and did not disagree with the deficient practice. 3. Resident #13 The resident was interviewed on 5/17/19 at 7:02 a.m. She said they had moved her last night back to her original private room and had set up her supplies in the closet. She said she was pleased because until now, she said, I felt scared every day, because no one knew what they were doing and she began to cry. The emergency equipment was also observed in the room and was located at the head of the bed in a bag labeled [MEDICAL CONDITION]. There was a document in the bag to indicate the necessary supplies that would remain in the bag.

Based on record review and interviews, the facility failed to prevent abuse inflicted by one (#5) of 14 sample residents toward Resident #7 and other residents. Specifically, the facility failed to keep Resident #7 and other residents safe from harm from Resident #5 by not consistently monitoring Resident #5. These failures resulted in Resident #7 feeling unsafe in her home and afraid of Resident #5. Findings include: I. Facility policy and procedure The Abuse policy, last revised (MONTH) (YEAR), was provided by the nursing home administrator (NHA) 5/20/19 at 5:50 p.m. and read in pertinent part: Every resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. II. Resident status Resident #5, age 73, was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 5/22/19 minimum data set (MDS) assessment documented the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. He rejected care, wandered, which caused a risk of getting to a dangerous place and intruding on the privacy of others. He had verbal and other behavioral symptoms that were directed toward others. He required extensive assistance for all activities of daily living (ADLs). III. Record review Care plan The care plan, initiated 10/23/18 and most recently revised on 4/15/16, documented the resident was in a reported altercation with another resident. The goal was for the resident to learn better ways to deal with his anger through the review period. The interventions included monitoring for 72 hours and 15-minute checks as needed, separate the resident from other residents and attempt to redirect. B. Progress notes The nurse progress note dated 4/20/19 documented, RN reported to this writer that resident kicked another resident in the lobby. Resident began screaming, cursing, repeatedly shouting, 'come on! I'm going to get you!' Staff separated residents but resident became fixated on all residents in the lobby. The nurse progress notes dated 4/20/19 documented, Upon return inside facility resident began screaming again and appeared to still focus on male residents. The nurse progress notes dated 4/20/19 documented, Resident was agitated for unknown reason, he started to move towards another resident yelling 'move' and kicked other resident in shin. The nurse progress notes dated 4/23/19 documented, Resident was by the door yelling 'ahh. ahh,' non-redirectable and would not stop yelling, he stated he wanted his shorts off. Asked if he would go to his room and we could change him, he started yelling 'no' repeatedly. Resident took his shoes and socks off and went outside with a staff member, was trying to wheel himself and would not stop. Resident came back in briefly scratched his face causing it to bleed, and then proceed to swing on staff member. The nurse progress notes dated 5/2/19 documented, Since return from hospital resident has been verbally and physically aggressive with staff. The nurse progress notes dated 5/5/19 documented, Nurse contacted resident's sister to inform her of physical alteration involving resident and another resident. The nurse progress notes dated 5/20/19 documented, Resident continues at times to have agitation and agitation and aggression and not able to be redirected for meals and is offered alternatives. There were no additional progress notes in the resident record related to the resident-to-resident incidents. C. Behavior notes The nurse progress notes dated 3/20/19 documented, Resident was kicking the glass door in the front lobby, staff member offered to take him outside for a walk. Resident was agitated and refused to come back inside. The nurse progress notes dated 4/10/19 documented, Resident up in wheelchair propelled self in hallways and entering another resident's room. Resident appears to be a little agitated. Resident kept saying 'come on, come on.' The nurse progress notes dated 5/4/19 documented, Resident was in the dining room during lunch and started yelling at random people to 'get out' several residents became upset and started yelling. The nurse progress notes dated 5/6/19 documented on 5/6/19 at 12:32 p.m. a behavior note which read, When another resident would change spots in lobby, (Resident #5) would continue to follow behind that resident, eventually telling other residents 'Get out.' The nurse progress notes dated 5/12/19 documented, Resident has been sleeping in lobby since 5:10 a.m. CNA (sitter) followed (Resident #5), and resident yelled at staff. IV. Resident interview Resident #7 was interviewed during a group interview on 5/7/19 at approximately 2:00 p.m. She said, I don't feel safe in the facility and I have told staff. Resident #7 was interviewed on 5/7/19 at 7:15 p.m. She said facility staff had placed a stop sign at her door to deter other resident from coming in. She said a few days ago Resident #5 had come into her room at night and grabbed her shower chair that was sitting in the middle of her room. She started screaming and grabbed her reacher and started swinging it at him. She said the nursing home administrator had come in and asked her if she felt safe and she reported that she did not. She said at that time the NHA started 15 minute checks on Resident #7. She said right now I'm afraid of him, he is unpredictable and I don't know what he will do. She added I'm not sure what good the stop sign is either. V. Staff interviews Certified nurse aide (CNA) #10 was interviewed on 5/7/19 at 7:25 p.m. She said the resident's mood varied. Sometimes he was screaming and yelling and then he would laugh and be sweet. She said he used to roam around rooms. She said he liked country music and loved the cool air. CNA #3 was interviewed on 5/7/19 at 7:30 p.m She stated the resident had several incidents over the last several months. She stated the interventions for the resident were to leave him alone and let him stay in the lobby. The assistant director of nursing (ADON) was interviewed on 5/7/19 at 7:40 p.m. She said she had talked with Resident #7 and she told her she still did not feel safe, but declined a one-on-one sitter. She said the resident had told her she felt defenseless when in bed. The staff development manager (SDM) and health information manager (HIM) were interviewed on 5/7/19 at 8:15 p.m. They were standing in the lobby near Resident #5. Both said that administrative facility staff had started one-on-one supervision for the resident on 5/7/19 at 7:45 p.m. (30 minutes before the interview). The NHA, director of nursing (DON) and division VP of clinical services (DVPCS) were interviewed on 5/7/19 at 8:16 p.m. The DVPCS said that they needed to increase their reactions to situations like this, and said she believed facility staff were so used to this resident that his behavior had become normal. She agreed that what the facility was currently doing was not working. The NHS and DON confirmed that one-on-one supervision for the resident had been implemented as of 7:45 p.m. on 5/7/19.

Based on interviews and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse and/or mistreatment of [REDACTED].#88, #81, #64, #30, #86, #61, #23, #18, #45, #27, #71, #75, and #31. Specifically, the facility failed to implement policies and procedures on the investigation of all alleged violations of abuse and/or mistreatment, the reporting of all alleged violations of abuse and/or mistreatment, and the protection of residents from harm due to abuse and/or mistreatment. The facility failure to prevent and address abuse contributed to an environment in the facility in which residents felt humiliated, dehumanized, intimidated, and fearful of retaliation, and staff said they feared for their jobs and felt powerless to protect residents from abuse. Findings include: I. Facility system to prevent abuse and/or mistreatment Review of the facility Abuse and Neglect Prohibition policy revealed it included expectations regarding the immediate investigation of allegations of abuse and/or mistreatment, immediate reporting to abuse and/or mistreatment to the administrator and the State Agency, and immediate correction of a situation of abuse and/or mistreatment, including immediate suspension of any employee alleged to be involved in an instance of abuse and/or mistreatment. In pertinent part, the facility Abuse and Neglect Prohibition policy, revised (MONTH) (YEAR), read: -Each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat the resident's medical symptoms. -Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator. -Facility supervisors will immediately investigate and correct reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation of resident property is at risk for occurring. -Staff will be instructed to report any signs of stress from employees, family and other individuals involved with the resident that may lead to abuse, neglect, injuries of unknown origin, or misappropriation of resident property and to intervene as appropriate. -Any employee alleged to be involved in an instance(s) of abuse and/or neglect will be interviewed and suspended immediately, and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. The facility Abuse and Neglect Prohibition policy further read, STATE REPORTING OBLIGATIONS: The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment including injuries of unknown origin, and misappropriation of property to the administrator, State Survey Agency, law enforcement officials and adult protective services where state law provides for jurisdiction in long-term care facilities in accordance with Federal and State law established procedures. Interview on 4/11/18 at 1:20 p.m. and 4/19/18 at 10:23 a.m. with the district director of clinical services (DDCS) and the regional vice president (RVP), respectively, revealed the facility also had a corporate Customer Service Satisfaction hotline for residents, staff, family and other visitors to report complaints about the facility and resident care and services. II. Facility failure to implement the above policies, procedures, and hotline to protect residents from abuse A. Cross reference F600; failure to protect residents from abuse and/or mistreatment. Interviews and record review, three (#88, #81 and #64) of ten residents reviewed for alleged abusive behavior towards them by staff. The incidents involving Residents #88 and #81, witnessed by staff and residents, were not reported by staff to corporate leadership or to state agencies (Cross reference F607 and F610). When an allegation was reported to corporate leadership by Resident #64, it not timely pursued (Cross reference F835). B. Cross reference F610; failure to respond to allegations of abuse and/or mistreatment Interviews and record review revealed the facility failed to have evidence all alleged violations of abuse and/or mistreatment were thoroughly investigated and failed to ensure protecction from further potential abuse and/or mistreatment after allegations of abuse and/or mistreatment were known for three (#88, #81, and #64) of ten residents reviewed for abuse of 45 sample residents. Specifically, the facility failed to: -Have evidence of a thorough, timely investigation for a witnessed incident of potential abuse of Resident #88 by the nursing home administrator (NHA) occurring in (MONTH) (YEAR) when such investigation was requested on (MONTH) 10, (YEAR). -Conduct a thorough investigation of a witnessed incident of potential abuse of Resident #81 by the NHA and the director of nursing (DON) and of other potential incidents of abuse reported to staff by administrative staff. -Have evidence of a thorough investigation for an allegation of potential mistreatment of [REDACTED]. -Take steps to prevent further potential abuse or mistreatment; administrative staff involved in the incidents above remained in the facility and on-duty for weeks after the incidents of abuse and/or mistreatment, some of which were witnessed and one of which was reported to the facility corporation. C. Cross reference F609; failure to ensure allegations were reported to the State Survey Agency Interviews and record review revealed the facility failed to ensure alleged violations related to abuse and/or mistreatment were timely reported to the State Survey Agency for three (#88, #81, and #64) of ten residents reviewed for abuse concerns. III. Effect on residents and staff of systemic failures in implementation of the facility's policies, procedures, and hotline to protect and prevent abuse and/mistreatment. A. Resident interviews Interviews with residents throughout the facility revealed facility failures in having an effective system for identifying and addressing concerns with the administrator and DON resulted in residents feeling mistreated (degraded, unimportant, imprisoned) , frightened and fearful of retaliation (kicked out, sent away). Resident #62 was interviewed on 4/9/18 at 1:55 p.m., and on 4/19/18 at 11:59 a.m. The resident said he had concerns with NHA and DON's conduct. According to the resident, shortly after the NHA's arrival around February, (YEAR), the NHA and DON told residents they did not care if residents stayed there at the facility because they would have a job either way. The resident said the DON was mean and would talk down to him. The resident said the NHA and DON's approaches made him feel like he was in prison and he was being punished for his misfortune and for being sick. The resident said this made him feel degraded and not important. The resident said he was unaware of anyone who could address his concerns with the NHA and DON. The resident said he felt worried for his well-being. Resident #59, alert and oriented per 2/28/18 MDS was interviewed on 4/9/18 at 3:45 p.m. The resident said the NHA, social services director (SSD), ADON and DON talk down to her, like she is zero. She said she feels humiliated when they speak to her like she is a child, or when she is accused of wrongdoing. She said these administrative staff charge in like an army to her room and rake you over the coals, and it scares and frightens her. She said that she did not understand why they all had to come in at once to tell her what she was doing wrong. She said she was afraid to say anything about how she was treated; she did not want anyone to hurt her. Resident #72, who was alert and oriented and admitted with nicotine dependence, was interviewed on 4/16/18 at 4:02 p.m. The resident explained he had to be supervised when he went out to smoke because of old holes in his pants. He explained he and the NHA had an argument over it. He said he was upset and felt he was being punished. Record review revealed no smoking assessment in the resident's record and no documented violations of the facility smoking policy. See F550 for further details. A group interview with 11 alert and oriented residents selected by the facility was conducted on 4/11/18 at 10:30 a.m. Residents #30, #64, #86, #61, #23, #18, #45, #27, #71, #75, and #31 were present for the meeting. Eight out of 11 residents reported fear of retaliation by the facility when reporting concerns. Comments from the attendees included: -Resident #30 said the NHA acted like a dictator. She said she worried she would be kicked out if she complained about her treatment. Resident #30 said the recent rule changes at the facility made her feel like the facility was more like a prison and less like her home. Resident #30 said she felt like she lost her right to speech, pursuit of happiness and the right to have someone listen to her concerns. -Resident #31 said he worried if he complained the NHA would retaliate by making more unfavorable changes to the facility rules. Other residents in the group voiced agreement with this statement. -Resident #64 said she had tried to talk to a staff member about concerns and the staff member had them move to a place they could not be overheard. Resident #64 said the NHA had told the residents, These are the rules. Follow them or leave. The resident said this statement made her afraid she was going to get sent away. Other residents voiced agreement with Resident #64's statement. -Resident #61 said the NHA was not nice. He felt concerned about punishment or retaliation for complaining about changes made at the facility. None of the residents in the group knew who they could go to with their concerns about the NHA. See F600 for further details B. Staff interviews Physical therapist assistant (PTA #1) was interviewed on 4/9/18 at 4:25 p.m. The PTA reported witnessing the NHA, who was accompanied by a high ranking nurse, demanding payment from the resident and refusing to leave while the PTA was providing personal care to the resident with the assistance of PTA #2. (Cross reference F550 and F600) PTA #1 said she did not report the NHA's mistreatment of [REDACTED]. CNA #17and #18 were interviewed together on 4/11/18 at 11:01 a.m. They said they felt intimidated by the NHA, SSD and DON feared retaliation in the form of being fired if they reported how these administrative staff abuse and mistreated Resident #81. They said they did not know how to report them, since they were in charge and were causing it, and did not know to whom to report them, so they did not report what they saw and overheard to anyone. Both indicated they feared losing their jobs; CNA #17 said she could not be without work as she had family to support. CNA #7 who was present, agreed with CNA #18 and #17 and said she felt hopeless to tell anyone as nothing would happen. CNA #19, who also worked with Resident #81, was interviewed on 4/12/18 at 4:00 a.m. She said she thought the NHA was very verbally abusive toward Resident #81. However, while she had told RN #4 about it how Resident #81 was treated, she feared retribution to report abuse to the NHA. RN #4, to whom CNA #19 reported how Resident #81 was treated, stated in an interview on 4/12/18 at 4:12 a.m. and 4:58 a.m. said she did not tell anyone what she had overheard about administrative staff's behavior toward Resident #81. CNA #16, LPN #3, and RN #4 were interviewed on 4/19/18 at 2:40 p.m. The CNA said she had heard resident complaints about treatment by the NHA. The CNA said she did not know to whom she should direct such complaints. LPN #3 said when the NHA arrived in February, (YEAR), the NHA informed staff that she (the NHA) was the reason staff had their jobs. LPN #3 understood the NHA's statement as reminder the NHA could fire staff who did not agree with the NHA. CNA #16 and RN #4 said they had similar reports from other staff about the NHA making such statements, though they reported being absent from the meeting where this announcement occurred. The receptionist was interviewed on 4/10/18 at 4:46 p.m. The receptionist said she knew to report abuse to the NHA. She said she was not sure to whom she should report allegations of abuse involving the NHA. The van driver was interviewed on 4/12/18 at 8:30 a.m. The driver said abuse was supposed to be reported to the NHA. She did not see how she could report abuse involving the NHA to the NHA. The driver said she did not know who else she could go to report abuse. The ADON was interviewed on 4/19/18 at 12:17 p.m. The ADON said she either reported abuse to the NHA or the DON. The ADON said she had been unaware of to whom she should report abuse allegations involving the NHA, other than the DON. CNA #15 was interviewed on 4/19/18 at 11:52 a.m. The CNA said prior to a recent training (during survey) she would not have known how to report an alleged abuse incident involving the NHA. The customer service representative was interviewed on 4/19/18 at approximately 11:00 a.m. She said she was aware how the NHA and the DON had spoken with Resident #81. She said she provided the resident with the ombudsman phone number to report her treatment. She said she did not report it as she was not aware who to report it to, as it involved the administration. See F835 for further details.

Based on observations, interviews and record review, the facility was not administered in manner that enabled it to use its resources efficiently and effectively to attain and maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically: The resources of the facility were not effectively and efficiently utilized as evidenced by findings that revealed in part: -The facility failed to protect residents from staff-to-resident abuse by the nursing home administrator (NHA), director of nursing (DON) and other members of facility administration. -The facility failed to implement its written policies to prohibit and prevent abuse and mistreatment. -The facility failed to report alleged incidents of abuse and mistreatment, reported to or witnessed by facility and corporate staff, to the State Survey Agency. -The facility failed to thoroughly investigate alleged incidents of abuse and mistreatment, known to or witnessed by staff, and failed to protect residents from further potential abuse by the NHA, DON and other members of the facility administration. -The facility failed to treat residents with dignity and respect and failed to protect their rights. These failures contributed to an environment where residents felt degraded, dehumanized, demeaned, punished, fearful, angry and intimidated and staff felt powerless to protect residents. Cross-reference F550, F559, F578, F580, F600, F609, F610, F657, F676, F679, F684, F688, F689, F695, F732, F744, F745, F756, F758, F842, and F880. Findings include: I. Resident Rights Cross reference F550: The facility failed to treat residents with respect and dignity. This contributed to nine residents feeling degraded, demeaned, humiliated, punished, fearful, angry, and like their rights had been stripped from them. Cross reference F559: The facility failed to promote resident rights related to notification of room change or roommate change for five residents. Cross reference F578: The facility failed to promote resident rights related to formulating advanced directives for one resident. Cross reference F580: The facility failed to notify a family member of one resident's health incidents. II. Freedom Abuse, Neglect, Exploitation Cross reference F600: The facility failed to prevent and address abuse contributing to an environment in the facility where residents felt humiliated, dehumanized, intimidated and fearful of retaliation and staff felt powerless to protect residents from abuse. Cross reference F607: The facility failed to implement policies to prevent and prohibit abuse contributing to an environment in the facility where residents felt humiliated, dehumanized, intimidated and fearful of retaliation and staff felt powerless to protect residents from abuse. Cross reference F609: The facility failed to report allegations of abuse and mistreatment to the State Survey Agency, contributing repeat incidents of abuse and/or mistreatment by administrative staff which left residents intimidated and fearful of retaliation and staff felt powerless to protect residents from abuse. Cross reference F610: The facility failed to have evidence all alleged abuse and mistreatment was thoroughly investigated and residents were protected from further potential abuse contributing to an environment in the facility where residents felt humiliated, dehumanized, intimidated and fearful of retaliation and staff felt powerless to protect residents from abuse. III. Comprehensive Resident Center Care Plans Cross reference F657: The facility failed to revised one resident's care plan to reflect her care and service needs. IV. Quality of Life Cross reference F676: The facility failed to provide one resident the services necessary to maintain her abilities to carry out activities of daily living. Cross reference F679: The facility failed to ensure an ongoing program of activities to meet a resident's interest for one resident. V. Quality of Care Cross reference F684: The facility failed to ensure quality of care related to administration of fast-acting insulin and administration of oxygen. Cross reference F688: The facility failed to ensure one resident appropriate services, equipment and assistance to maintain or improve range of motion. Cross reference F689: The facility failed to consistently implement safety care plans related to resident safe smoking devices and resident fall prevention for two residents. Cross reference F695: The facility failed to respiratory care consistent with physician orders [REDACTED]. VI. Nursing Services Cross reference F732: The facility failed to have a system to ensure required nurse staffing was posted. VII. Behavioral Health Services Cross reference F744: The facility failed to ensure one resident reviewed for dementia care received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being. Cross reference F745: The facility failed to ensure ancillary services were offered and provided for one resident related to dental and vision needs. VIII. Pharmacy Services Cross reference F756: The facility failed to have evidence it acted upon recommendations by the pharmacist based on medication regimen review (MRR). Cross reference F758: The facility failed to ensure residents reviewed for medications were free from unnecessary drugs. IX. Administration Cross reference F842: The facility failed to have an effective system to ensure medical records were complete and accurate. X. Infection Control Cross reference F880: The facility failed to maintain an infection control and prevention program designed to provide a sanitary environment and prevent the development and transmission of disease and infection. XI. Interviews A. Resident interviews revealed concerns with alleged abuse, mistreatment and undignified conduct towards residents by facility administration Interviews with residents #81, #29, #62, #84, #59, #64, #88, #30, #72, and #26 revealed conduct by the nursing home administrator (NHA), director of nursing (DON), assistant director of nursing (ADON), social services director (SSD) and other members of administration resulted in residents feeling humiliated, degraded and fearful of retaliation by the administration. 1. Resident #81, in an interview on 4/9/18 at 10:46 a.m. said she had been harassed and humiliated by administrative staff. Resident #81 said the NHA spoke to her in a manner and tone that was harassing and demeaning in front of the DON, and activity director (AD) who accompanied the NHA to the resident's room. The resident said the incident also witnessed by two members of therapy staff who were providing cares when the NHA, DON and AD entered the resident's room. The resident said she felt humiliated to the point of tears and powerless. Cross reference to F550 further details regarding dignity concerns and F600 for further details regarding mistreatment allegations related to administration's conduct towards Resident #81. 2. Resident #29, in an interview on 4/9/18 at 1:37 p.m., described having her room searched three times without her knowledge or permission by a whole crew of administration. The resident said the administration staff went through her drawers and they took her scissors. She said it was demeaning and made her angry because they went through all of her belongings. Resident #29 said the NHA, DON and ADON would approach residents in bunches to tell you what you did wrong, resulting in the resident feeling demeaned. Cross reference to F550 for further details regarding dignity concerns by administration towards Resident #29. 3. Resident #62, in an interview on 4/9/18 at 1:55 p.m. said the NHA and the DON did not treat residents with respect and dignity. The resident said the NHA talked down to residents like we are children. The resident said he was concerned because the NHA and DON wanted to make him a supervised smoker because he had a history of [REDACTED]. The resident said the NHA's and DON's approach made him feel like he was in prison and he was being punished for his misfortune and for being sick. Cross reference to F550 for further details regarding dignity concerns by administration towards Resident #62. 4. Resident #84, in an interview on 4/9/18 at 3:11p.m., said the office people (administrative staff) on Hall 1, do not treat him with respect or dignity except for the social worker, the restorative therapy staff and the activities people. He said the NHA runs the facility like a dictator. The resident said NHA did not listen to him during care conferences. The resident said the DON approached him with six staff trying to get him to use a long-handled wiping device. He said the DON's approach humiliated and embarrassed him. The resident said he was fearful of saying anything because of repercussions. Cross reference to F550 for further details regarding dignity concerns by administration towards Resident #84. 5. Resident #59, in an interview on 4/9/18 at 3:45 p.m., said the NHA, SSD, ADON and DON talk down to her, like she is a zero. She said she feels humiliated when they speak to her like she is a child, or when she is accused of wrongdoing. She said these administrative staff charge in like an army to her room and rake you over the coals, and it scares and frightens her. Cross reference to F550 for further details regarding dignity concerns by administration towards Resident #59. 6. Resident #64, in an interview on 4/10/18 at 8:12 a.m., said the NHA addressed her and other residents in a bullish and abusive manner that made her feel like a two year-old child. The resident said the NHA threatened to discharge residents, change resident smoking status from unsupervised to supervised, and to prohibit residents from eating meals in their rooms. Resident #64, in an interview on 4/10/18 at 4:17 p.m., said she witnessed an alleged abuse incident between the NHA and Resident #88. Resident #64 said witnessing the incident left her feeling afraid for herself and other residents. Cross reference to F550 for further details regarding dignity concerns by administration towards Resident #64 and F600 for further details regarding alleged abuse/mistreatment by the administration towards Resident #64 and Resident #88. 7. Resident #88, alert and oriented per 3/29/18 minimum data set (MDS), reported in an interview on 4/10/18 at 3:01 p.m. that in (MONTH) (YEAR), the nursing home administrator (NHA) yelled at him, grabbed his wheelchair, placed him in her office and blocked his attempts to leave. When he finally left the office, the NHA followed him and continued to yell at him in front of residents and staff in the common area. Cross reference to F600 for further details regarding alleged abusive behavior by administrative staff toward Resident #88. 8. Resident #30, in a group interview on 4/11/18 at 10:30 a.m., said the NHA acted like a dictator and she said she worried she would be kicked out if she complained about her treatment. Resident #30 said the recent rule changes at the facility made her feel like the facility was more like a prison and less like her home. Resident #30 said she felt like she had lost her right to speech, pursuit of happiness and the right to have someone listen to her concerns. Cross reference to F550 for further details regarding dignity concerns by administration towards Resident #30. 9. Resident #72 reported in an interview conducted on 4/16/18 at 4:02 p.m., the DON had accused him of using heroin and called the physician assistant to have his pain medication discontinued. The resident said the NHA made he feel punished for having holes in his pants because was designated a supervised smoker after old holes were identified in his clothing. Cross reference to F550 for further details regarding dignity concerns by administration towards Resident #72. 10. Resident #26 reported in an interview conducted on 4/19/18 at 11:56 a.m., the DON was mean to him and had an approach that felt like a sneak attack. The resident said the DON had confronted him in a rude, accusatory manner when he did not meet her expectations for signing out of the building, even though the resident had informed his nurse and had obtained medicines for his time out of the building. Cross reference to F550 for further details regarding dignity concerns by administration towards Resident #26. 11. A group interview with 11 alert and oriented residents selected by the facility was conducted on 4/11/18 at 10:30 a.m. Residents #30, #64, #86, #61, #23, #18, #45, #27, #71, #75, and #31 were present for the meeting. Five of the residents said they had concerns with how the facility administration treated them. Specifically, the residents reported the facility administration did not treat them with respect and dignity. -Resident #61 said the DON and NHA were disrespectful to residents in a meeting held to announce new smoking rules. The resident said meeting was a mess and upset every resident in attendance. Multiple residents voiced agreement with resident #61's description of the treatment provided at the smoking meeting. -Resident #64 said DON and NHA were so rude to the residents at the smoking meeting that residents began walking and wheeling out to get away from the meeting. Resident #61 and Resident #88 agreed that residents were upset exited the smoking meeting before its conclusion. -Resident #30 said another way the facility administration failed to provide residents with respect and dignity was related to room searches. Resident #30 said facility administration would come and look for contraband in resident rooms. -Resident #23 reported it upset her when staff searched her room. Resident #64 said the administration had taken items from Resident #23's room. B. Staff Interviews Interviews with staff confirmed resident reports of mistreatment and undignified treatment by the facility administration. Staff reported feeling powerless to address resident concerns because they feared losing their jobs. 1. Certified nurse aide (CNA) #7, #17 and #18 reported in an interview conducted on 4/11/18 at 11:01 a.m., they did not know how to report allegations of abuse or mistreatment involving the NHA, DON and the SSD because the NHA, DON and SSD were in charge and were causing the abuse. CNA #17 and CNA #18 reported being fearful of losing their jobs as a retaliation from the administration. CNA #7 reported feeling hopeless and that she could not report her concerns about the conduct NHA and DON towards residents. 2. CNA #19 reported in an interview conducted on 4/12/18 at 4:00 a.m., that she feared retribution from the NHA if she reported abuse concerns regarding the NHA's treatment of [REDACTED]. 3. Interviews with the receptionist on 4/10/18 at 4:46 p.m. and the van driver on 4/12/18 at 8:30 a.m. revealed each staff member witnessed an alleged incident of abuse by the NHA toward Resident #88. Both staff expressed fear of losing their jobs if they expressed their concerns to the facility's abuse coordinator, who was the NHA. Both said they did not know to whom they should report allegations of abuse or mistreatment involving the NHA. 4. CNA #16, licensed practical nurse (LPN) #3, and RN #4 were interviewed on 4/19/18 at 2:40 p.m. All of the staff members reported hearing resident complaints of how administration had treated residents during the smoking meeting where new rules for smoking were announced. The LPN said the NHA informed staff that she (the NHA) was the reason staff had their jobs. LPN #3 understood this to mean the NHA could fire staff that did not agree with the NHA. XII. Leadership Interviews The Director of Clinical Services (DDCS) and consulting nursing home administrator (CNHA) reported in an interview conducted on 4/16/18 at 8:05 a.m. that facility staff had expressed fear of losing their jobs if they reported the facility administration for abuse concerns. The DDCS said it was upsetting to her that staff felt fearful of losing their jobs. The DDCS said she could have helped the staff with the concerns and could have transferred the staff to another facility within the area if the staff remained fearful. The regional vice president for operations (RVP) was interviewed on 4/19/18 at 10:23 and 10:45 a.m. -The RVP acknowledged that Resident #64 (see interview above) had lodged a complaint about mistreatment of [REDACTED]. He did not know about the complaint in a timely manner, however, because an email to him was sent to his other folder, which he seldom checked. -The RVP confirmed the facility was not being administered in accordance with expectations, particularly as it related to resident dignity and the prohibition of resident abuse/mistreatment. The RVP said the administration did not consult him about changes to the smoking policy. The RVP said it was not company policy for administration to approach residents in groups and he understood how residents might feel uncomfortable with that approach because it was not person-centered. The RVP said it was his expectation that staff should report allegations of abuse involving facility administration and that administration should report such allegations to their consultants and should place themselves on leave pending the outcome of the investigation. The medical director (MD) was interviewed on 4/19/18 at 3:15 p.m. The MD said he was new to the facility having been there less than six months. The MD said the NHA and DON had not consulted him about policy changes related to smoking. The MD said the administration should have given more consideration to such policy changes because the facility's residents had already experienced such a high cost of admission to the facility such loss of home, loss of good health and loss of many personal effects, such that additional restrictions to the resident choice and freedom could be detrimental. The MD said the smoking policy change was not in keeping with person-centered care.

Based on interviews and record review, the facility failed to have evidence all alleged violations of abuse and/or mistreatment were thoroughly investigated and failed to ensure protecction from further potential abuse and/or mistreatment after allegations of abuse and/or mistreatment were known for three (#88, #81, and #64) of ten residents reviewed for abuse of 46 sample residents. (Cross reference F600, F607 and F609). Specifically, the facility failed to: -Have evidence of a thorough, timely investigation for a witnessed incident of potential abuse of Resident #88 by the nursing home administrator (NHA) occurring in (MONTH) (YEAR) when such investigation was requested on (MONTH) 10, (YEAR). -Conduct a thorough investigation of a witnessed incident of potential abuse of Resident #81 by the NHA and the director of nursing (DON) and of other potential incidents of abuse reported to staff by administrative staff. -Have evidence of a thorough investigation for an allegation of potential mistreatment of [REDACTED]. -Take steps to prevent further potential abuse or mistreatment; administrative staff involved in the incidents above remained in the facility and on-duty for weeks after the incidents of abuse and/or mistreatment, some of which were witnessed and one of which was reported to the facility corporation. The facility failure to thoroughly investigate allegations of potential abuse and mistreatment and failure to take steps to protect residents from the alleged perpetrator when the allegations were known to facility leadership created an environment where residents felt fearful and intimidated. Findings include: I. Facility Abuse Policy In pertinent part, the facility Abuse and Neglect Prohibition policy, revised (MONTH) (YEAR), read: -Facility supervisors will immediately investigate and correct reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation of resident property is at risk for occurring. -Any employee alleged to be involved in an instance(s) of abuse and/or neglect will be interviewed and suspended immediately, and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. II. Residents #88, #81, #64 - Failures in timely and thoroughly investigating alleged abusive behavior by administrative staff A. Resident #88 1. Resident status Resident #88, age [AGE] years, was admitted to the facility on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The 3/29/18 minimum data set (MDS) comprehensive assessment documented the resident was cognitively intact as evidenced by a brief interview for mental status (BIMS) score of 14 out of 15. The resident did not exhibit any behavioral symptoms that impacted him or others during the assessment observation period. 2. Resident #88 interview - alleged abusive behavior by administrative staff in (MONTH) (YEAR) Resident #88, in an interview on 4/10/18 at 3:01 p.m. reported that in (MONTH) (YEAR), the nursing home administrator (NHA) yelled at him, grabbed his wheelchair, placed him in her office and blocked his attempts to leave. When he finally left the office, the NHA followed him and continued to yell at him in front of residents and staff in the common area. Cross reference to F600 for further details regarding alleged abusive behavior by administrative staff toward Resident #88. 3. Staff interviews regarding behavior of administrative staff toward Resident #88 and failure of the facility to investigate the (MONTH) (YEAR) incident. a. The receptionist, in an interview on 4/10/18 at 3:44 p.m. and 4:46 p.m., reported witnessing the (MONTH) (YEAR) incident between the NHA and Resident #88, which she said was also witnessed by the assistant director of nursing (ADON). The receptionist's account of the incident was consistent with the resident's account of the incident. The receptionist said no one from the facility had interviewed her as part of an investigation into the (MONTH) (YEAR) incident. b. The van driver (driver), in an interview on 4/12/18 at 8:30 a.m., reported witnessing the (MONTH) (YEAR) incident between the NHA and Resident #88. The driver's account of the (MONTH) (YEAR) incident was consistent with Resident #88's account of the incident between the resident and the NHA. The driver said no one from the facility had interviewed her as part of an investigation in the days immediately after the incident. c. The ADON, in an interview on 4/19/18 at 12:17 p.m., reported intervening in the (MONTH) (YEAR) incident between the NHA and Resident #88, directing the receptionist remove the resident to smoking area and redirecting the NHA. The ADON said she reported the incident to the director of nursing (DON), who was her direct supervisor. 4. Facility record review and administration interview Notwithstanding the ADON's statement she had reported the (MONTH) (YEAR) incident to the DON, review of facility records and request for any documentation regarding an investigation of the (MONTH) (YEAR) incident on 4/10/18 confirmed no documentation of a facility investigation incident and no documentation of corrective actions taken by the facility to prevent future abusive incidents between Resident #88 and the NHA. The district director of clinical services (DDCS) and NHA were interviewed on 4/9/18 at 4:46 p.m. The NHA and DDCS denied having any abuse investigations involving the NHA. B. Resident #81 1. Resident status Resident #81, age 65, was admitted on [DATE]. According to the (MONTH) (YEAR) CPO, [DIAGNOSES REDACTED]. According to the 3/29/18 MDS assessment, the resident had no cognitive impairment with a BIMS score of 15 out of 15. She required extensive assistance with transfers. There were no mood or behaviors noted. According to the care plan, initiated and revised on 2/6/18, the resident was identified as having limited physical mobility related to [MEDICAL CONDITION], neurological deficits, and history of stroke. Interventions included to provide assistance with mobility. According to the care plan, initiated on 1/26/18 and revised on 2/6/18, the resident had a mood problem related to generalized anxiety disorder. Interventions included to assist in developing a program of meaningful activities of interest. Per the (MONTH) CPO, the resident was receiving [MEDICATION NAME] for anxiety. 2. Resident interview - alleged abusive behavior by administrative staff Resident #81 was interviewed on 4/09/18 at 10:46 a.m. She reported she had been harassed and humiliated by administrative staff. She said one day, during the last week of (MONTH) (YEAR), the NHA entered her room, uninvited with the DON and the Activity Director (AD). Her door was closed because she was partially undressed; her pants were pulled down half way for a dressing change by the therapy staff. The resident said the NHA spoke to her in a manner and tone which was not dignified, but rather harassing and demeaning. She said she repeatedly asked the NHA and others to leave her room. She said the NHA refused to leave, but instead continued to talk to her in loud and harsh tone and in a demanding manner about money she owed the facility. She said it made her angry, and she felt humiliated to the point of tears and as well as powerless. 3. Staff interviews regarding behavior of administrative staff toward Resident #81 and facility failure to report and thoroughly investigate allegations. The activity assistant (AA) was interviewed on 4/9/18 at 4:00 p.m. The AA said that she had a good rapport with the resident and that the resident had confided in her that she had not been treated with respect by the NHA and other administrative staff. The AA said the resident cried when she (the resident) talked about her treatment by administration. The AA said she felt really bad for the resident. Physical therapist assistant (PTA) #1 was interviewed on 4/9/18 at 4:25 p.m. The PTA said she was in the room along with PTA #2 providing care to Resident #81 when the incident describe by the resident (see above) occurred. PTA #1 said that the resident said she felt humiliated as she was receiving care at the time. The PTA said she told the resident to contact the ombudsman. The PTA said she did not report the NHA's mistreatment of [REDACTED]. The PTA had not been interviewed by facility staff regarding the incident. PTA #2 was interviewed on 4/10/18 at approximately 9:00 a.m. PTA #2 said he was in the room along with PTA #1 providing care to Resident #81 when the incident described by the resident (see above) occurred. He said the NHA and the administration nurse were in the room for approximately 15 minutes. The PTA said that he had worked with the resident a lot and that every time the NHA was near, her demeanor would change and he saw an increase in anxiety. The PTA had not been interviewed by facility staff regarding the incident. CNAs #7, #17, and #18, interviewed on 4/11/18 at 11:01 a.m. confirmed they had overheard the NHA and DON speak harshly and rudely to Resident #81 regarding money they said the resident owed the facility. They also said they were aware the NHA made excuses to prevent the resident going to activity outings. CNA #17 and #18 said they were not interviewed by the facility about the NHA, DON, and SSD abuse allegations towards residents either before or the two days since the facility was informed by the survey team of NHA, DON, and SSD abuse allegations toward residents. CNA #19 interviewed on 4/12 at 4:00 a.m. The CNA revealed Resident #81 had spoken to her about not being allow to go on outings she had signed up for. She said she feared retribution to report abuse to the NHA and said she, too, had not been interviewed either before or in the three days since the facility was informed by the survey team of allegations of abuse of residents involving NHA, DON and SSD. RN #4 on 4/12/18 at 4:12 a.m. and 4:58 a.m. revealed she had overheard the resident tell the CNAs that she had been approached by the NHA, SSD and DON in a threatening manner that made the resident cry. RN #4 said she did not tell anyone what she had heard Resident #81 tell the CNAs, even though CNA #19 said she reported the administrative staff's threatening behavior to her. She, too, said she had not been interviewed by the facility about allegations of abuse by the NHA, DON, and SSD toward residents. CNA #5 was interviewed on 4/12/18 at 4:56 a.m., three days after the facility was informed of NHA, DON, and SSD abuse allegations towards residents. She said she had not been interviewed by the facility about allegations of abuse by the NHA, DON, and SSD toward residents. Cross reference F600 for further details on staff interviews 4. Record review - Facility investigation incomplete Review of facility investigations on abuse, neglect and mistreatment revealed no investigation of incidents involving Resident #81 in (MONTH) or (MONTH) (YEAR). See CNA interviews above, stating they were not interviewed about Resident #81's allegations of abuse by administrative staff either before or after abuse allegations were reported to the facility by the survey team. The NHA and DDCS were interviewed on 4/09/18 at 4:36 p.m. Both denied having investigations related to the NHA, DON, and other facility leaders regarding Resident #81's allegations or the allegation administrative staff approached residents together or spoke to residents in a manner perceived as mean or threatening. The DDCS and CNHA were interviewed on 4/10/18 at 5:52 p.m. The DDCS said the facility would not be substantiating Resident #81's allegations. The DDCS said they had interviewed the SSD, the DON and the NHA and they all had the same story, which was that Resident #81 had invited them in and insisted they speak with her while cares were provided. However, the DDCS and CNHA acknowledged they had not interviewed therapy staff (PTA #1 and PTA #2) who were had witnessed to the incident. C. Resident #64 1. Resident status Resident #64, age 54, was admitted on [DATE]. According to the 3/18 CPO, [DIAGNOSES REDACTED]. According to the 3/6/18 MDS assessment, the resident had no memory problems. She had a BIMS score of 15 out of 15. Resident #64 needed varying assistance with activities of daily living due to cognitive changes weakness, and shortness of breath. The care plan, initiated 11/7/17 and revised 3/16/18, identified the resident as being on antidepressants and anti-anxiety medications related to nightmares from experiences; and adjustment issues from having suffered some personal loss. Resident was also grieving the news of her daughter and son being in a severe motor accident, needing to undergo surgeries, and healing process. 2. Resident interview - failure to investigate allegation of mistreatment Resident #64 was interviewed on 4/10/18 at 8:12 a.m. Resident #64 said the NHA addressed her and other residents with a tone of voice, an attitude, with gestures, and with mannerisms that were bullish, abusive and uncalled for. She said this was threatening as well as humiliating, made her feel like a two year old child, and recalled for her a violent family trauma from childhood. -She said the NHA had threatened to discharge residents that did not follow the rules and that failure to follow the NHA's new rules on smoking would result in all residents being unable to smoke in the facility again. She thought her change in smoking status from independent to supervised was punishment. -She said she called the corporate Senior Care Satisfaction line to report the abuse and mistreatment she and other residents were experiencing at the hands of the administrative staff several weeks ago, but had not received any follow up. According to a document provided by the DDCS, Resident #64 called the corporate Senior Care Satisfaction line on 3/28/18 at 1:07 p.m. to lodge a complaint about mistreatment of [REDACTED]. According to the tracking information on the document, Resident #64 called the Senior Care Satisfaction line on the 3/28/18 at 1:07 p.m. See F600 for further details on Resident #64's allegations of abuse and/or mistreatment. III. Failure to prevent further potential abuse and/or mistreatment by administrative staff after witnessed incident of abuse A. Witness Interviews The receptionist, in an interview on 4/10/18 at 3:44 p.m. and 4:46 p.m. and the van driver (driver), in an interview on 4/12/18 at 8:30 a.m., said the NHA remained on duty at the facility after the (MONTH) (YEAR) incident occurred. B. Administration Interviews 1. Allegations involving Residents #88 and #81 Interviews with administration confirmed the NHA and DON continued to work in the facility, with no interventions to prevent further abuse of residents, after witnessed incidents of alleged abuse and/or mistreatment involving the NHA and Resident #88, and the NHA, DON and Resident #81. Residents were not protected from further potential abuse and/or mistreatment by the NHA and DON in the weeks between these incidents and initiation of the facility's investigation. Moreover, a call to the facility's corporate compliance line, alleging mistreatment by the NHA, had not received a response. The district director of clinical services (DDCS) and NHA were interviewed on 4/9/18 at 4:46 p.m. See above; the NHA and DDCS denied having any abuse investigations involving the NHA. Minutes after the interview with the DDCS and the NHA concluded, the DDCS approached and reported that the NHA, DON and other members of administrative staff had been placed on administrative leave, per facility policy in order to prevent further abuse, pending the outcome of abuse investigation involving residents #81. (Resident #88's and #64's abuse/mistreatment had not been discovered at this time.) The DDCS and consulting nursing home administrator (CNHA) were interviewed on 4/10/18 at 5:52 p.m. The DDCS said the NHA and DON were first suspended pending completion of investigation into allegations of abuse on 4/9/18. The DDCS and CNHA said they did not have an investigation into (MONTH) (YEAR) incident between the NHA and Resident #88. The DDCS said the NHA and DON would remain on administrative leave pending the outcome of the investigation into Resident #88's abuse allegations. The DDCS and CNHA, in an interview on 4/16/18 at 8:05 a.m., said abuse allegations reported by Resident #88 and #81 were substantiated. 2. Allegations by Resident #64 The DDCS, in an interview on 4/11/18 at 1:20 p.m. said there was a trace of Resident #64's call to the Customer Service Satisfaction Line on 3/28/18 at 1:07 p.m. (see resident interview above) She said the communication team left a voicemail and sent an email to the Regional Vice President (RVP) on same day. According to the DDCS, she called the RVP on 4/18/18 and the RVP said he missed both the voice and emails from the communication team, resulting in the delay in response. The RVP was interviewed on 4/19/18 at 10:23 a.m. He said he did not realize there was a communication sent to him on Resident #64's complaint until the DDCS mentioned it through a phone call. He said the email to him was sent to his other folder, which he seldom checked, therefore, he did not see the communication until he talked with the DDCS. Cross reference to F600 for further details regarding interviews with the DDCS, CNHA, and RVP and facility failures to investigate allegations of abuse and mistreatment. IV. Interviews with residents throughout the facility revealed facility failures in having an effective system for identifying and addressing concerns with the administrator and DON resulted in residents feeling mistreated (degraded, unimportant, imprisoned) , frightened and fearful of retaliation (kicked out, sent away). Resident #62 was interviewed on 4/9/18 at 1:55 p.m., and on 4/19/18 at 11:59 a.m. The resident said he had concerns with NHA and DON's conduct. According to the resident, shortly after the NHA's arrival around February, (YEAR), the NHA and DON told residents they did not care if residents stayed there at the facility because they would have a job either way. The resident said the DON was mean and would talk down to him. The resident said the NHA and DON's approaches made him feel like he was in prison and he was being punished for his misfortune and for being sick. The resident said this made him feel degraded and not important. The resident said he was unaware of anyone who could address his concerns with the NHA and DON. The resident said he felt worried for his well-being. Resident #59, alert and oriented per 2/28/18 MDS was interviewed on 4/9/18 at 3:45 p.m. The resident said the NHA, social services director (SSD), ADON and DON talk down to her, like she is zero. She said she feels humiliated when they speak to her like she is a child, or when she is accused of wrongdoing. She said these administrative staff charge in like an army to her room and rake you over the coals, and it scares and frightens her. She said that she did not understand why they all had to come in at once to tell her what she was doing wrong. She said she was afraid to say anything about how she was treated; she did not want anyone to hurt her. A group interview with 11 alert and oriented residents selected by the facility was conducted on 4/11/18 at 10:30 a.m. Residents #30, #64, #86, #61, #23, #18, #45, #27, #71, #75, and #31 were present for the meeting. Eight out of 11 residents reported fear of retaliation by the facility when reporting concerns. Comments from the attendees included: -Resident #30 said the NHA acted like a dictator. She said she worried she would be kicked out if she complained about her treatment. Resident #30 said the recent rule changes at the facility made her feel like the facility was more like a prison and less like her home. Resident #30 said she felt like she lost her right to speech, pursuit of happiness and the right to have someone listen to her concerns. -Resident #31 said he worried if he complained the NHA would retaliate by making more unfavorable changes to the facility rules. Other residents in the group voiced agreement with this statement. -Resident #64 said she had tried to talk to a staff member about concerns and the staff member had them move to a place they could not be overheard. Resident #64 said the NHA had told the residents, These are the rules. Follow them or leave. The resident said this statement made her afraid she was going to get sent away. Other residents voiced agreement with Resident #64's statement. -Resident #61 said the NHA was not nice. He felt concerned about punishment or retaliation for complaining about changes made at the facility. None of the residents in the group knew who they could go to with their concerns about the NHA.

Based on interviews and record review, three (#88, #81 and #64) of ten residents, reviewed for alleged abusive behavior towards them by staff out of 46 sample residents, alleged abuse. The incidents involving Residents #88 and #81, witnessed by staff and residents, were not reported by staff to corporate leadership or to state agencies (Cross reference F607 and F610). When an allegation was reported to corporate leadership by Resident #64, it not timely pursued (Cross reference F835). The facility failure to prevent and address abuse contributed to an environment in the facility in which residents felt humiliated, dehumanized, intimidated, and fearful of retaliation, and staff said they feared for their jobs and felt powerless to protect residents from abuse. Findings include: I. Facility Abuse Policy In pertinent part, the facility Abuse and Neglect Prohibition policy, revised (MONTH) (YEAR), read: -Each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat the resident's medical symptoms. -Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator. -Facility supervisors will immediately investigate and correct reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation of resident property is at risk for occurring. -Staff will be instructed to report any signs of stress from employees, family and other individuals involved with the resident that may lead to abuse, neglect, injuries of unknown origin, or misappropriation of resident property and to intervene as appropriate. -Any employee alleged to be involved in an instance(s) of abuse and/or neglect will be interviewed and suspended immediately, and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. II. Residents #88, #81, and #64 - Alleged abusive behavior by administrative staff A. Resident #88 1. Resident status Resident #88, age [AGE] years, was admitted to the facility on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The 3/29/18 minimum data set (MDS) comprehensive assessment documented the resident was cognitively intact as evidenced by a brief interview for mental status (BIMS) score of 14 out of 15. The resident did not exhibit any behavioral symptoms that impacted him or others during the assessment observation period. The resident required supervision for mobility on and off the unit and was mobile with the use of a wheelchair. 2. Resident #88 interview - alleged abusive behavior by administrative staff in (MONTH) (YEAR) Although Resident #88 stated on 4/9/18 at 1:14 p.m. that he had not been abused, when re-approached on 4/10/18 at 3:01 p.m., the resident said around the middle of (MONTH) (YEAR), he was speaking with the bus (van) driver when the NHA walked over to him, grabbed his wheelchair, informed him You are coming with me! and took him to her office. -The resident said he was taken to the NHA's office where he was confronted by the NHA. Licensed practical nurse (LPN) #1 was in the NHA's office; the LPN had reported to the NHA that he had said something derogatory about LPN #1 and the NHA was yelling at him for that. -The resident said he was not allowed to leave the NHA's office; even though he made multiple attempts to go, the NHA repeatedly blocked his exit. The resident said when he was able to get out of the NHA's office, the NHA followed him back to the day room and yelled at him in front of staff and other residents. The resident said the incident ended when the assistant director of nursing (ADON) interrupted the NHA. -The resident said at the time of the incident, he felt upset and humiliated because he was taken away to the woodshed by then NHA and then he was yelled at in front of his peers and staff. -The resident said he had concerns with treatment by other staff, specifically LPN #1 a few months back. The resident said his concern, which involved waiting for medications and not receiving medications, was resolved when LPN #1 was removed from providing his care. 3. Staff and resident interviews regarding behavior of administrative staff toward Resident #88 Staff and resident interviews confirmed Resident #88's report of abusive behavior toward him by the NHA in (MONTH) (YEAR). Staff interviews further revealed other potential incidents of abuse by administrative staff toward Resident #88 and failure by staff to ensure all potential allegations of abuse by administrative staff were reported and investigated. a. The receptionist was interviewed on 4/10/18 at 3:44 p.m. and 4:46 p.m. The receptionist said she saw the incident between Resident #88 and the NHA that occurred in (MONTH) (YEAR) because the incident happened by her desk. -She said the NHA was yelling at the resident and the resident responded to NHA by yelling back at the NHA. She characterized the incident as verbal abuse by the NHA because the NHA should not yell at residents. -She said the incident ended when the ADON came from her office and directed her to remove the resident to the outside smoking area and the ADON redirected the NHA away from the resident. -She said no one from the facility had talked to her about the incident between Resident #88 and the NHA. The receptionist said she did not report the incident to anyone because she believed the ADON, who witnessed the incident, had made such a report. b. Resident #64, who witnessed the incident (MONTH) (YEAR) incident between Resident #88 and the NHA, was interviewed on 4/10/18 at 4:17 p.m. -Resident #64 said the NHA tore into Resident #88 in front of everyone and then dragged Resident #88 into the NHA's office. Resident #64 said she believed the incident she witnessed was verbal abuse of Resident #88. She said witnessing the incident made her feel afraid for herself, Resident #88, and the other residents. -Resident #64 said she worried the NHA could yell at her and no one would stop it. c. LPN #1, who was in the office with the NHA and Resident #88 during the (MONTH) (YEAR) incident, was interviewed on 4/12/18 at 5:48 a.m. (See resident interview above and family member interview below regarding LPN #1's removal from providing care to the resident prior to the (MONTH) (YEAR) incident.) -She said the NHA was talking loudly to Resident #88. She confirmed the NHA closed the door each time Resident #88 attempted to leave the NHA's office by twisting the door knob and opening it a few inches. -She said she did not feel comfortable with the NHA preventing Resident #88 from leaving the office and said she reported the incident to registered nurse (RN) #1. d. The van driver (driver) was interviewed on 4/12/18 at 8:30 a.m. The driver said she witnessed an incident between the NHA and Resident #88 around the middle to end of (MONTH) (YEAR). -The driver said the NHA began yelling at the resident in the day room and then removed the resident to her office. The driver said she did not see the outcome of the incident because she had somewhere to be with another resident. The driver said she did not report the (MONTH) (YEAR) incident to the director of nursing (DON) because she previously had observed the DON yelling at the resident and waving her finger in the resident's face. The driver said she thought the DON would not be receptive to any report of abuse involving Resident #88 because the DON had exhibited inappropriate behavior toward the resident. -The driver said she thought she had talked with the ADON and the staff development coordinator (SDC) about her concerns for Resident #88 and his interactions with the NHA and DON. The driver reiterated she did not go to NHA or the DON about the abuse concerns because they would not be receptive. -The driver said no one from the facility had interviewed about the incident between NHA and Resident #88 in the days following incident. e. The ADON was interviewed on 4/19/18 at 12:17 p.m. The ADON acknowledged witnessing the (MONTH) (YEAR) incident between Resident #88 and the NHA. -The ADON said the NHA and the resident were yelling at each other in the lobby and the sound caused her to come from her office to investigate. The ADON said the NHA should not have been yelling at the resident. The ADON said she told the receptionist to take Resident #88 to the smoking area in order to deescalate the situation. -The ADON said she reported the incident to her supervisor, the DON. 4. Resident #88's family member (POA) interview Interview with the POA revealed concerns with Resident #88's safety in the facility, his treatment by administrative staff, and possible retaliation. The POA was interviewed on 4/11/18 at 12:01 p.m. The POA said she visited the resident almost daily in order to make certain the resident was okay. -She said the DON had a history of [REDACTED].#88, waving a finger in his face and threatening to issue a 30-day involuntary discharge notice to the resident. She said her concerns for the resident increased when the NHA arrived at the facility in (MONTH) (YEAR); before that, her only concern was how the DON interacted with the resident. She said the NHA did not like the resident and was targeting him for retaliation. -She said the NHA approached her on 4/3/18 and told her she (the NHA) wanted to me (the POA) to know she was going to find a way to issue Resident #88 a 30-day notice no matter what. She said the NHA told her the facility just needed to figure out a reason to issue the notice so it met regulatory requirements and then she (the NHA) would call a taxi and have the resident dropped off at the POA's house. These statements by the NHA created additional concern for Resident #88's safety. -The POA said she had heard about the incident in (MONTH) (YEAR) between Resident #88 and the NHA from Resident #88 and another resident who was Resident #88's friend. The POA said Resident #88's friend had expressed fear for Resident #88's safety because of how he was treated by the NHA. She said no one from the facility had contacted her about the (MONTH) incident. She said if the NHA was willing to yell at Resident #88 in front of staff and other residents, she was concerned about what other actions the NHA might take. -The POA said she knew about the resident's difficulty with other staff. The POA said LPN #1 had been removed from providing care for the resident. The POA said she believed the LPN was removed from providing the resident's care before the (MONTH) (YEAR) incident. 5. Additional staff interviews CNA #17 was interviewed on 4/12/18 at 5:26 a.m. The CNA said she knew the resident and had worked with him routinely on day and night shifts. The CNA said she noticed the lately the resident had more issues with conduct. The CNA said she noticed the resident stayed in his room more and did not come out to visit. The CNA said she noticed the change shortly after the NHA arrived. RN #2 was interviewed on 4/12/18. The RN said she had been taking care of the resident for a while. The RN said she began providing nursing services to the resident months ago when LPN #1 was removed from providing care to resident. The RN said she did not know what happened between LPN #1 and the resident, but the result was the resident and LPN did not like one another. The RN said she noticed the resident had been having [MEDICAL CONDITION] more frequently. According to the RN, the resident's [MEDICAL CONDITION] were brought on by stress and anxiety. 6. Facility investigation confirmed the (MONTH) (YEAR) incident and confirmed staff failures in reporting and investigating the incident and in protecting Resident #88. The district director of clinical services (DDCS) and consulting nursing home administrator (CNHA) were interviewed on 4/10/18 at 5:52 p.m. The DDCS and CNHA said there was no investigation of an alleged abusive incident between Resident #88 and the NHA in (MONTH) (YEAR), although, see above; per the interviews, the incident was witnessed and reported to the DON. The DDCS and CNHA said the resident had not disclosed the incident with the NHA when they interviewed him as part of a facility-wide interview process related to allegations of abuse involving the DON and NHA. The DDCS and CNHA said they would follow-up with Resident #88 and possible witnesses. The DDCS and CNHA were interviewed again on 4/16/18 8:05 a.m., regarding their investigation of the (MONTH) (YEAR) incident between the NHA and Resident #88. The DDCS said the investigation was not complete and ready for review, but would be finalized later that day. -The DDCS provided the initial report made on 4/10/18, documenting the incident. The CNHA said the resident spoke to her about the (MONTH) (YEAR) incident with the NHA, and the report was consistent with the resident's original report of the incident. (See Resident #88 interview above). The CNHA said the resident reported being upset by the incident and did not like being treated like a child. -The DDCS and CNHA said interviews confirmed the resident had been taken to the NHA's office against his will and the NHA yelled at the resident in a public area with staff and residents witnessing the incident. The DDCS and CNHA said they were substantiating the allegations of abuse of Resident #88 by the NHA. B. Resident #81 1. Resident status Resident #81, age 65, was admitted on [DATE]. According to the (MONTH) (YEAR) CPO, [DIAGNOSES REDACTED]. According to the 3/29/18 MDS assessment, the resident had no cognitive impairment with a BIMS score of 15 out of 15. She required extensive assistance with transfers. There were no mood concerns or behaviors noted. According to the care plan, initiated and revised on 2/6/18, the resident was identified as having limited physical mobility related to [MEDICAL CONDITION], neurological deficits, and history of stroke. Interventions included to provide assistance with mobility. According to the care plan, initiated on 1/26/18 and revised on 2/6/18, the resident had a mood problem related to generalized anxiety disorder. Interventions included to assist in developing a program of meaningful activities of interest. Per the (MONTH) CPO, the resident was receiving [MEDICATION NAME] for anxiety. 2. Resident #81 interview - alleged abusive behavior by administrative staff Resident #81 was interviewed on 4/09/18 at 10:46 a.m. She reported she had been harassed and humiliated by administrative staff. -She said one day, during the last week of (MONTH) (YEAR), the NHA entered her room, uninvited with the DON and the Activity Director (AD). Her door was closed because she was partially undressed; her pants were pulled down half way for a dressing change by the therapy staff. -She said the NHA spoke to her in a manner and tone which was not dignified, but rather harassing and demeaning. She said neither the DON nor AD interjected to make the NHA stop speaking to her in that way or to suggest it was inappropriate to talk to her during the dressing change. -She said she repeatedly asked the NHA and others to leave her room on this occasion (as well as another with the NHA, SSD, and DON). She said the administrative staff would refuse to leave, and in the instance described above, continued to talk to her in loud and harsh tone and in a demanding manner about money she owed the facility. She said when the administrative staff would refuse to leave her room, it made her angry, and she felt humiliated to the point of tears, degraded, as well as powerless in her own home. She said she had notified the ombudsman last Wednesday (4/4/18) and asked her to submit a complaint with the State. She also said she told Activity Assistant (AA) what had happened. 3. Staff interviews confirming incidents involving Resident #81 and administrative staff The activity assistant (AA) was interviewed on 4/9/18 at 4:00 p.m. The AA said she had concerns with how resident #81 was treated as an individual. The AA said that she had a good rapport with the resident and that the resident had confided in her that she had not been treated with respect by the NHA and other administrative staff. She said the resident cried when she (the resident) talked about her treatment by administration. The AA said she felt really bad for the resident. The physical therapist assistant (PTA #1) was interviewed on 4/9/18 at 4:25 p.m. The PTA said she was in the room providing care to Resident #81. She said that she and another therapist were transferring the resident with a sit-to-stand mechanical lift. She said that the NHA, and a high ranking nurse, came into the room while she was providing personal hygiene to the resident. The NHA said that they needed to talk about the resident's outstanding bill. The resident asked the NHA and the nurse to leave and to come back later. The NHA responded to the resident in a firm, matter of fact tone, I will leave when you give me a check for $2200 dollars. The PTA #1 said that the resident said felt humiliated as she was receiving care at the time. The PTA said she told the resident to contact the ombudsman. The PTA said she did not report the NHA's mistreatment of [REDACTED]. PTA #2 was interviewed on 4/10/18 at approximately 9:00 a.m. The PTA #2 said he and PTA #1 were providing care for Resident #81 when administration staff entered the resident's room. He said he and PTA #1 were transferring the resident out of bed and the NHA and an administration nurse entered the room and said We need to talk about your stay. The NHA started asking the resident about financial issues. He said the NHA's behavior was very unprofessional and inappropriate. He said the resident asked them to leave, and the NHA said that she needed a check from the resident. He said the NHA and the administration nurse were in the room for approximately 15 minutes. The PTA said that he had worked with the resident a lot and that every time the NHA was near, her demeanor would change and he saw an increase in anxiety. CNA #7, #17, and #18 were interviewed on 4/11/18 at 11:01 a.m. They said they had witnessed the NHA and the DON abuse Resident #81 as described by Resident #81 (see above) as well as at other times. They said it appeared to them the NHA was trying to get rid of Resident #81. -Both CNA #17 and #18 said the resident was signed up to go on an outing a couple of weeks ago but was not allowed to go. They overheard the NHA and DON tell the resident in a harsh, rude tone of voice that she owed the facility money and accused the resident of buying things online, instead of paying the facility. The CNAs said the NHA made excuses for not allowing the resident to go on the outing, such as saying she needed a doctor ' s order which the resident already had. The CNAs also said this was not the only time the resident was not allowed on an outing, even though she was first on the list to go. (Review of the resident's activity participation records confirmed the resident did not attend outings on several days in (MONTH) (YEAR)) -CNA #18 said last week as she transferred Resident #81 to her commode, the NHA entered the room, uninvited, and spoke to the resident in a harsh tone, demanding she pay the facility money what she owed. She said Resident #81 told the NHA she was not dressed and CNA #18 told the NHA she was almost done providing care to the resident. However, the NHA did not leave and continued to insist the resident owed money. -CNA #17 said a few weeks ago, the NHA entered the resident's room with the DON, uninvited, as she was trying to put Resident #81 on a bedpan. She said the NHA started yelling at Resident #81 about money she owed the facility. CNA #19 was interviewed on 4/12/18 at 4:00 p.m. She said Resident #81 had spoken to her about not being allowed to go on outings and said it humiliated her. The CNA said she encouraged Resident #81 to report it. The CNA said she told RN #4 about it, who told her that it had been reported to the ombudsman and she had heard said RN #1 had told the SSD about it. RN #4 was interviewed on 4/12/18 at 4:12 a.m. She said she overheard Resident #81 tell the CNAs she was approached in a threatening manner by the NHA, the SSD, and other administrative staff a few weeks ago about a bill not being paid. She said she heard Resident #81 say it made her cry and that she had told the NHA and the others to get out of her room. RN #4 said she felt sad for the resident because the facility was her home. RN #4 said she did not tell anyone what she had overheard Resident #81 tell the CNAs. 4. Record review and administrative interviews Review of Resident #81's record and facility records on abuse investigations revealed no documentation of Resident #81's allegations of abuse and/or mistreatment and no documentation of incidents reported by CNAs (see above). -Review of the resident's (MONTH) (YEAR) and (MONTH) (YEAR) progress notes revealed there was no documentation regarding the incidents described above by Resident #81 and the CNAs above. -Review of facility investigations on abuse, neglect and mistreatment revealed no investigation of incidents involving Resident #81. The NHA and DDCS were interviewed on 4/09/18 at 4:36 p.m. Both denied having investigations related to the NHA, DON, and other facility leaders regarding Resident #81's allegations or the allegation administrative staff approached residents together or spoke to residents in a manner perceived as mean or threatening. The DDCS and CNHA were interviewed on 4/10/18 at 5:52 p.m. The DDCS said the facility would not be substantiating Resident #81's allegations. The DDCS said they had interviewed the SSD, the DON and the NHA and they all had the same story, which was that Resident #81 had invited them in and insisted they speak with her while cares were provided. However, the DDCS and CNHA acknowledged they had not interviewed therapy staff who were had witnessed to the incident occuring the last week of (MONTH) (YEAR). The DDCS said they would interview therapy staff in order to have a complete investigation. C. Resident #64 1. Resident status Resident #64, age 54, was admitted on [DATE]. According to the 3/18 CPO, [DIAGNOSES REDACTED]. According to the 3/6/18 MDS assessment, the resident had no memory problems. She had a BIMS score of 15 out of 15. Resident #64 needed varying assistance with activities of daily living due to cognitive changes weakness, and shortness of breath. The care plan, initiated 11/7/17 and revised 3/16/18, identified the resident as being on antidepressants and anti-anxiety medications related to nightmares from experiences; and adjustment issues from having suffered some personal loss. Resident was also grieving the news of her daughter and son being in a severe motor accident, needing to undergo surgeries, and healing process. 2. Resident interview - alleged threats of retaliation Resident #64 was interviewed on 4/10/18 at 8:12 a.m. Resident #64 said the NHA addressed her and other residents with a tone of voice, an attitude, with gestures, and with mannerisms that were bullish, abusive and uncalled for. She said this was threatening as well as humiliating, made her feel like a two year old child, and recalled for her a violent family trauma from childhood. -She said the NHA threatened the residents with discharge, stating in a first meeting with the residents that she was in charge of the facility, so if any resident was unwilling to abide by her rules, she could show them the door. The NHA also told them the facility was not a homeless shelter where anybody could do what he or she wanted. Therefore, no one should go out beyond the bounds of the facility without obtaining the appropriate permission and if found going against the rules, the resident would be thrown out. The NHA also told them if anyone thought the rules were too stringent to follow, she was willing to give that resident some cash as a parting gift for them to leave the facility. -She said the NHA also had also threatened residents about smoking. She said the NHA changed her smoking status from independent to supervised because she had a history of [REDACTED]. She said the NHA although she had no smoking infractions and told her and others if the new smoking rules were not followed, she (NHA) would not allow anyone to smoke in the facility again. -She also said the NHA threatened that she would not be allowed to eat meals in her room anymore because she expected every resident to go to the dining room for their meals. -She said she called the corporate Senior Care Satisfaction line to report the abuse and mistreatment she and other residents were experiencing at the hands of the administrative staff several weeks ago, but had not received any follow up. 3. Record review and administrative interview The District Director of Clinical Services (DDCS) was interviewed on 4/11/18 at 1:20 p.m. She said there was a trace of the resident's call to the Senior Care Satisfaction Line on 3/28/18 at 1:07 p.m. She said the communication team left a voicemail and sent an email to the Regional Vice President (RVP) on same day. According to the DDCS, she called the RVP on 4/18/18 and the RVP said he missed both the voice and emails from the communication team, resulting in the delay in response. According to a document provided by the DDCS, Resident #64 called the corporate Senior Care Satisfaction line on 3/28/18 at 1:07 p.m. to lodge a complaint about mistreatment of [REDACTED]. According to the tracking information on the document, Resident #64 called the Senior Care Satisfaction line on the 3/28/18 at 1:07 p.m. The RVP was interviewed on 4/19/18 at 10:23 a.m. He said he did not realize there was a communication sent to him on Resident #64's complaint until the DDCS mentioned it through a phone call. He said the email to him was sent to his other folder, which he seldom checked, therefore, he did not see the communication until he talked with the DDCS. He said he rarely checked voicemail. III. Circumstances contributing to failures in preventing abuse and reporting and investigating incidents of abuse a. Interviews revealed additional concerns about administrator and director of nursing Cross reference F550 for resident and staff interviews about how the NHA and DON conducted changes in facility smoking policy Record review and interviews revealed the facility failed to treat nine residents (#29, #81 #84, #62, #64, #72, #59, #26 and #30) in a respectful and dignified manner. Specifically, interviews revealed and confirmed staff engaged in the following practices: Searched and repeatedly entered resident rooms without permission; accused a resident of illegal drug use; changed resident smoking status without evidence of cause; approached residents in groups; and spoke to residents in a disrespectful and threatening manner. b. Staff interviews revealed concerns about the NHA and DON Cross reference to F835 Administration for staff interviews about NHA conduct and fear for their jobs. CNAs #17 and #18, both of whom worked with Resident #81, were interviewed on 4/11/18 at 11:01 a.m. CNA #7 was also present for the interview. CNAs #17 and #18 said they felt intimidated by the NHA, DON and SSD and feared retaliation in the form of being fired if they reported how these administrative staff abuse and mistreated Resident #81. They said they did not know how to report the NHA, DON and SSD, since they were in charge and were causing the abuse. CNAs #17 and #18 did not know to whom to report their concerns with the NHA, DON and SSD, so they did not report what they saw and overheard to anyone. CNA #7 said she felt hopeless and felt she could not tell anyone about her concerns with the NHA and DON because nothing would happen. CNA #19, who also worked with Resident #81, was interviewed on 4/12/18 at 4:00 a.m. She said she had heard about the NHA not permitting Resident #81 to go on outings. She said the administrative staff treated the resident like a kid, scolding her. She thought the NHA was very verbally abusive toward Resident #81. However, while she had told RN #4 about it how Resident #81 was treated, she feared retribution to report abuse to the NHA, RN #4, to whom CNA #19 reported how Resident #81 was treated, stated in an interview on 4/12/18 at 4:12 a.m. and 4:58 a.m. said she did not tell anyone what she had overheard about administrative staff's behavior toward Resident #81. CNA #16, LPN #3, and RN #4 were interviewed on 4/19/18 at 2:40 p.m. The CNA said she had heard resident complaints about treatment by the NHA. The CNA said she did not know to whom she should direct such complaints. LPN #3 said when the NHA arrived in February, (YEAR), the NHA informed staff that she (the NHA) was the reason staff had their jobs. LPN #3 understood the NHA's statement as reminder the NHA could fire staff who did not agree with the NHA. CNA #16 and RN #4 said they had similar reports from other staff about the NHA making such statements, though they reported being absent from the meeting where this announcement occurred. CNA #16, RN #4 and LPN #3 reported the NHA was not approachable. According to LPN #3, the NHA had told staff they were not permitted to enter her office, which contributed to the belief the NHA was not approachable. LPN #3 and RN #4 said the NHA did not speak to direct-care staff. The LPN said she noticed the NHA frequently took the DON or other department heads with her when the NHA walked the halls. The RN, LPN, and CNA confirmed it was the NHA's practice to approach residents with at least one other member of facility leadership. The RN, LPN and CNA agreed residents might feel intimidated when approached by multiple members of the facility administration. c. Interviews with staff revealed a lack of system for addressing concerns with facility leaderships' conduct 1. Staff interviews reveal lack of training on reporting abuse incidents involving the NHA The receptionist was interviewed on 4/10/18 at 4:46 p.m. The receptionist said she knew to report abuse to the NHA. She said she was not sure to whom she should report allegations of abuse involving the NHA. The van driver was interviewed on 4/12/18 at 8:30 a.m. The driver said abuse was supposed to be reported to the NHA. She did not see how she could report abuse involving the NHA to the NHA. The driver said she did not know who else she could go to report abuse. The ADON was interviewed on 4/19/18 at 12:17 p.m. The ADON said she either reported abuse to the NHA or the DON. The ADON said she had been unaware of to whom she should report abuse allegations involving the NHA, other than the DON. CNA #15 was interviewed on 4/19/18 at 11:52 a.m. The CNA said prior to a recent training (see interview below with DDCS and CNHA), she would not have known how to report an alleged abuse incident involving the NHA. 2. Interview with the district director of clinical services (DDCS) and consultant nursing home administrator (CNHA) revealed training had been offered during survey when concerns with reporting abuse by a NHA were identified The DDCS and CNHA were interviewed on 4/16/18 8:05 a.m. The DDCS said that staff who witnessed alleged abuse incidents between facility leadership and Resident #88 and #81 reported either telling a supervisor or being afraid to

Based on record review and interviews, the facility failed to treat nine (#29, #81 #84, #62, #64, #72, #59, #26, and #30) of 46 sample residents in a respectful and dignified manner. Specifically, interviews revealed and confirmed staff engaged in the following practices: Searched and repeatedly entered resident rooms without permission; accused a resident of illegal drug use; changed resident smoking status without evidence of cause; approached residents in groups; and spoke to residents in a disrespectful and threatening manner. The facility's failure to treat residents with respect and dignity contributed to the residents feeling degraded (like a zero), demeaned (treated like a child), humiliated, punished (in prison), fearful, angry and, as if their rights as residents had been stripped from them. Cross reference F600; abuse. Findings include: I. Facility expectations According to the facility's policy on Resident Rights, revised on (MONTH) (YEAR) -the resident had a right to a dignified existence, and self-determination -the staff would treat each resident with respect and dignity, and care for them in a manner and environment which promoted the maintenance and enhancement of his/her quality of life, recognizing their individuality -the facility provided equal access to quality care regardless of diagnosis, severity of condition, and payment source -facility staff would not interfere, hamper, coerce, compel by force, treat differently or otherwise discriminate against, or retaliate against a resident for exercising his/her rights. Review of facility policies and programs revealed the facility had a Truly Listening to Our Customers (TLC) program that utilized ambassadors assigned to each resident, to identify and correct resident concerns and to ensure residents' dignity needs were met. Ambassadors were to provide residents daily, consistent contact with facility leadership. II. Facility failures - Approaching residents in a disrespectful, humiliating, demeaning and intimidating manner. Cross reference. F600 for further details. Facility failure to treat residents with respect and dignity, contributing to resident harm. A. Resident #29 1. Resident #29, age 62, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. According to the 1/25/18 minimum data set (MDS) assessment, the resident was cognitively intact; she had a score of 14 out of 15 for the brief interview for mental status (BIMS). She required extensive assistance with activities of daily living. 2. Room search The resident was interviewed on 4/9/18 at 1:37 p.m. The resident said that her room was searched three times. She said the room was searched each time without her knowledge or permission. She said the whole crew of administration went through her drawers and they took her scissors. She said it was demeaning and made her angry because they went through all of her belongings. She said she was told the administration searched resident rooms to look for drugs. Review of the resident's record failed to reveal documentation either that the resident's room had been searched or that the resident had provided consent to have her room searched. The social service director (SSD) was interviewed on 4/11/18 at 10:35 a.m. The SSD confirmed the resident's room was searched one time. She said it was searched because the resident was lethargic and she and three other staff searched the resident's room looking for sleeping drugs. She confirmed she did not receive permission to conduct the search and said she assumed it had been given. She said she was not aware of the other two searches reported by the resident. The SSD agreed resident rooms should not be searched without permission from the resident. The SSD was interviewed again on 4/11/18 at 11:10 a.m. She said after reviewing the resident's record, she had failed to document the search of the resident's room. Moreover, she agreed there was no documentation the resident had given permission for the search. 3. Approach to residents Resident #29, during her interview on 4/9/18 at 1:37 p.m. said, They (the nursing home administrator/NHA, Director of Nurses/DON and Assistant DON/ADON) come in bunches to tell you what you did wrong. She said that it was demeaning when they came into her room in such a manner. She said she attended a meeting which was held with the residents that smoked. She said the DON was demanding and overbearing at the meeting and she said she was forced to sign the smoking policy. She said the DON tried to scare the residents, citing new rules from the administration, the basis for which she did not understand. RN #1 was interviewed on 4/9/18 at approximately 4:15 p.m. and said she had witnessed the NHA, DON and SSD speak with residents as a group in regard to certain situations. She said she was not sure why they approached and spoke to residents in this manner. The district director of clinical services (DDCS) was interviewed on 4/10/18 at 9:30 a.m. The DDS said she it was not facility policy or practice for the staff to approach residents in a group. The SSD was interviewed on 4/11/18 at 10:35 a.m. She said she, the NHA and the DON and at times others, would talk to residents for various reasons. She said speaking to the resident as a group was for cares in pairs to ensure there were no misunderstandings. She said it had been this way since she had started in (MONTH) (YEAR). The SSD was interviewed a second time on 4/11/18 at 11:10 a.m. She said there was no policy on cares in pairs. She said it was used as an intervention on the care plan. C. Resident #59 1. Resident #59, alert and oriented per 2/28/18 MDS, was interviewed on 4/9/18 at 3:45 p.m. 2. The resident said the NHA, SSD, ADON and DON talk down to her, like she is zero. She said she feels humiliated when they speak to her like she is a child, or when she is accused of wrongdoing. She said these administrative staff charge in like an army to her room and rake you over the coals, and it scares and frightens her. She said that she did not understand why they all had to come in at once to tell her what she was doing wrong. She said she is afraid to say anything about how she was treated; she did not want anyone to hurt her. D. Resident #62 Resident #62 was interviewed on 4/9/18 at 1:55 p.m. and 4/19/18 at 11:59 a.m. The resident said staff at the facility did not treat residents with respect and dignity. The resident reported the following concerns: -The nursing home administrator (NHA) talked down to residents like we are children. The resident said, It makes me feel disrespected and unappreciated. -The resident explained he and other residents became upset with their treatment at meetings held for the purpose of discussing the rules for smokers. The resident said there were two meetings for smokers. According to the resident, in the first meeting the NHA would not let residents speak. He said this made him feel like he was in day care. -The resident said the NHA told residents she did not care if they stayed at the facility because she would still have a job. The resident said the NHA and other members of staff at the smoking meeting were short with the residents. -The resident said he had smoked safely, without incident, for years. Shortly after the NHA arrived, she wanted him put on supervised smoking because of his [MEDICAL CONDITION]. The resident said he would not sign the new smoking contract and he considered himself to be an independent smoker. He continued to smoke independently, but worried the administration would come and take his materials or that he would have to go offer property to smoke. -The resident said the facility attempting to take his freedom to smoke left him feeling humiliated and degraded. He said the NHA and DON's approaches made him feel like he was in prison and he was being punished for his misfortune and for being sick. The resident said this made him feel degraded and not important. The resident said he felt worried for his well-being. E. Resident #81 1. Resident #81, age 65, was admitted on [DATE]. According to the (MONTH) (YEAR) CPO, [DIAGNOSES REDACTED]. According to the 3/29/18 MDS assessment, the resident had no cognitive impairment with a BIMS score of 15 out of 15. She required extensive assistance with transfers. There were no mood or behaviors noted. According to the care plan, initiated and revised on 2/6/18, the resident was identified as having limited physical mobility related to [MEDICAL CONDITION], neurological deficits, and history of stroke. Interventions included to provide assistance with mobility. According to the care plan, initiated on 1/26/18 and revised on 2/6/18, the resident had a mood problem related to generalized anxiety disorder. Interventions included to assist in developing a program of meaningful activities of interest. Per the (MONTH) CPO, the resident was receiving [MEDICATION NAME] for anxiety. 2. Resident #81 interview Resident #81 was interviewed on 4/09/18 at 10:46 a.m. She reported she had been harassed and humiliated by administrative staff. -She said one day, during the last week of (MONTH) (YEAR), the NHA entered her room, uninvited with the DON and the Activity Director (AD). Her door was closed because she was partially undressed; her pants were pulled down half way for a dressing change by therapy staff. -She said the NHA spoke to her in a manner and tone which was not dignified, but rather harassing and demeaning. She said neither the DON nor AD interjected to make the NHA stop speaking to her in that way or to suggest it was inappropriate to talk to her during the dressing change. -She said she repeatedly asked the NHA and others to leave her room on this occasion (as well as another with the NHA, SSD, and DON). She said the administrative staff would refuse to leave, and in the instance described above, continued to talk to her in loud and harsh tone and in a demanding manner about money she owed the facility. She said when the administrative staff would refuse to leave her room, it made her angry and she felt humiliated to the point of tears, degraded, as well as powerless in her own home. She said she had notified the ombudsman last Wednesday (4/4/18) and asked her to submit a complaint with the State. She also said she told Activity Assistant (AA) what had happened. 3. Staff interviews The activity assistant (AA) was interviewed on 4/9/18 at 4:00 p.m. The AA said she had concerns with how resident #81 was treated as an individual. She said the resident was kept from going on an outing in relation to her outstanding facility bill. She said the resident had requested to go on an outing. The AA said the resident was on Medicare part A, so she understood that she needed to have a physician order [REDACTED]. The physician order [REDACTED]. The AA said she inquired the reason and she was not told the underlying issues. She said that she had heard it was in relation to the resident not paying her bill. She said that she had a good rapport with the resident and that the resident had confided in her that she had not been treated with respect. She said the resident cried when she (the resident) talked about her treatment by administration. The AA said she felt really bad for the resident. Physical therapy assistant (PTA) #1 was interviewed on 4/9/18 at 4:25 p.m. The PTA said she witnessed the incident described by Resident #81 (see above). The PTA said that the resident said felt humiliated as she was receiving care at the time. PTA #2 was interviewed on 4/10/18 at approximately 9:00 a.m. The PTA said he witnessed the incident describe by Resident #81 (see above). He said the NHA's behavior was very unprofessional and inappropriate. The PTA said that he had worked with the resident a lot and that every time the NHA was near, her demeanor would change and he saw an increase in anxiety. CNA #7, #17, and #18 were interviewed on 4/11/18 at 11:01 a.m. They said they had witnessed the NHA and the DON abuse Resident #81 as described by Resident #81 (see above) as well as at other times. -Both CNA #17 and #18 said the resident was signed up to go on an outing a couple of weeks ago but was not allowed to go. They overheard the NHA and DON tell the resident in a harsh, rude tone of voice that she owed the facility money and accused the resident of buying things online, instead of paying the facility. The CNAs said the NHA made excuses for not allowing the resident to go on the outing, such as saying she needed a doctor's order which the resident already had. The CNAs also said this was not the only time the resident was not allowed on an outing, even though she was first on the list to go. (Review of the resident's activity participation records confirmed the resident did not attend outings on several days in (MONTH) (YEAR)) -CNA #18 said last week as she transferred Resident #81 to her commode, the NHA entered the room, uninvited, and spoke to the resident in a harsh tone, demanding she pay the facility money what she owed. She said Resident #81 told the NHA she was not dressed and CNA #18 told the NHA she was almost done providing care to the resident. However, the NHA did not leave and continued to insist the resident owed money. -CNA #17 said a few weeks ago, the NHA entered the resident's room with the DON, uninvited, as she was trying to put Resident #81 on a bedpan. She said the NHA started yelling at Resident #81 about money she owed the facility. CNA #19 was interviewed on 4/12/18 at 4:00 p.m. She said Resident #81 had spoken to her about not being allowed to go on outings and said it humiliated her. The CNA said she encouraged Resident #81 to report it. The CNA said she told RN #4 about it, who told her that it had been reported to the ombudsman and she had heard said RN #1 had told the SSD about it. RN #4 was interviewed on 4/12/18 at 4:12 a.m. She said she overheard Resident #81 tell the CNAs she was approached in a threatening manner by the NHA, the SSD, and other administrative staff a few weeks ago about a bill not being paid. She said she heard Resident #81 say it made her cry and that she had told the NHA and the others to get out of her room. RN #4 said she felt sad for the resident because the facility was her home. Cross reference F600 for further details. 4. Record review According to the (YEAR) Ambassador Rounds sheets provided by the facility for Resident #81, the Activity Director (AD) was her Ambassador. There was no documentation reflecting the AD conducted daily Ambassador rounds with Resident #81 per the facility's expectations (see above). Rather, Resident #81 received Ambassador visits three times in (MONTH) (YEAR), two times in (MONTH) (YEAR), and once in (MONTH) (YEAR). E. Resident #64 1. Resident #64, age 54, was admitted on [DATE]. According to the (MONTH) (YEAR) CPO, [DIAGNOSES REDACTED]. According to the 3/6/18 MDS assessment, the resident had no memory problems. She had a BIMS score of 15 out of 15. Resident #64 needed varying assistance with activities of daily living due to cognitive changes weakness, and shortness of breath. The care plan, initiated 11/7/17 and revised 3/16/18, identified the resident as being on antidepressants and anti-anxiety medications related to nightmares from experiences; and adjustment issues from having suffered some personal loss. Resident was also grieving the news of her daughter and son being in a severe motor accident, needing to undergo surgeries, and healing process. 2. Resident interview - alleged threats of retaliation Resident #64 was interviewed on 4/10/18 at 8:12 a.m. Resident #64 said the NHA addressed her and other residents with a tone of voice, an attitude, with gestures, and with mannerisms that were bullish, abusive and uncalled for. She said this was threatening as well as humiliating, made her feel like a two year old child, and recalled for her a violent family trauma from childhood. -She said the NHA threatened the residents with discharge, stating in a first meeting with the residents that she was in charge of the facility, so if any resident was unwilling to abide by her rules, she could show them the door. The NHA also told them the facility was not a homeless shelter where anybody could do what he or she wanted. Therefore, no one should go out beyond the bounds of the facility without obtaining the appropriate permission and if found going against the rules, the resident would be thrown out. The NHA also told them if anyone thought the rules were too stringent to follow, she was willing to give that resident some cash as a parting gift for them to leave the facility. -She said the NHA also had also threatened residents about smoking. She said the NHA changed her smoking status from independent to supervised because she had a history of [REDACTED]. She said the NHA although she had no smoking infractions and told her and others if the new smoking rules were not followed, she (NHA) would not allow anyone to smoke in the facility again. -She also said the NHA threatened that she would not be allowed to eat meals in her room anymore because she expected every resident to go to the dining room for their meals. -She said she called the corporate Senior Care Satisfaction line to report the abuse and mistreatment she and other residents were experiencing at the hands of the administrative staff several weeks ago, but had not received any follow-up. 3. Staff interview CNA #5 was interviewed on 4/12/18 at 4:09 a.m. She stated there were many complaints about the smoking rule change from residents. She stated Resident #64 had night terrors and woke up in the middle of the night. She said, it (smoking) helped mellow and calm her down and she goes right back to bed but now residents are not allowed to smoke between 10:00 p.m. and 7:00 a.m. She said one night the DON took Resident #64 out to smoke. She said when the resident came back in she told the CNA she said she had not been spoken to like the DON had spoken to her since she was a child and said she felt she had lost her rights and her dignity. The CNA said she did not report the incident to the DON. She said, If I had reported it, nothing would have been done about it. Cross reference F600 for further details. F. Resident #30 1. Resident #30, age 71, was originally admitted on [DATE] and re-admitted on [DATE]. According to the (MONTH) (YEAR) CPO, [DIAGNOSES REDACTED]. According to 1/26/18 MDS assessment, the resident had no memory problems. She has a BIMS score of 14 out of 15. Resident #30 needed varying assistance with activities of daily living due to stroke-related weakness, and shortness of breath. The care plan, initiated on 8/31/17 identified the resident required assistance with activities of daily living. 2. Resident interviews Resident #30, in a group interview on 4/11/18 at 10:30 a.m. said the NHA acted like a dictator and she said she worried she would be kicked out if she complained about her treatment. Resident #30 said the recent rule changes at the facility made her feel like the facility was more like a prison and less like her home. Resident #30 said she felt like she had lost her right to speech, pursuit of happiness and the right to have someone listen to her concerns. Resident #30 was interviewed again on 4/17/18 at 10:15 a.m. She said the NHA made some disrespectful remarks about the residents who smoke in the facility. She said it was unprofessional for the NHA to say the facility was not a homeless shelter so residents could not do anything they wanted there. Resident #30 believed their rights as residents of the facility had been stripped off them. G. Resident #84 1. Resident #84, [AGE] years old, was admitted on [DATE]. According to the computerized physician orders [REDACTED]. According to the most recent annual MDS dated [DATE] and his most recent quarterly MDS dated [DATE], the resident's BIMS score was 15, indicating the resident was cognitively intact. 2. Resident interview The resident was interviewed on 4/9/18 at 3:11 p.m. He said he had resided at the facility for seven years. He said the office people (administrative staff) on Hall 1 (where all of the administrative offices were located), do not treat him with respect or dignity except for the social worker, the restorative therapy staff and the activities people. He became teary eyed as he discussed the following concerns: He said the NHA came in February, (YEAR), and he asked the social worker to set up a meeting with the NHA so he could introduce himself; however, he said he never got that meeting. Although the social worker said she told the NHA of his request, the NHA denied receiving it and said she was not responsible for something that happened weeks ago. He said the NHA runs the facility like a dictator. He said when he had a care conference, the people that attended (NHA, social worker, the DON and another nurse) were not all the people he wanted to have there. He said the NHA came in and pulled up his chart on her computer; he felt like she was not paying attention or listening to him. She told him he was yelling at her while never once looking him in the eye. He said there is no communication in the facility and the office people do not tell him the truth and put things off. He said the DON once told him she had contacted his doctor after he requested to see him, but when the doctor came in he said he was never contacted by the DON. He said about five to six months ago he went to a pain clinic but he did not meet the criteria to be seen so he turned in the paper they gave him to the nurse and when she brought the original back to him, he put it in a book and left for therapy. When he returned, the original paper was gone, the stuff he had on his bed was messed up and extra copies of the paper were on his table. He said an aide told him two office people from Hall 1 came to his room; one person stayed outside the room while the other was in his room. Finally, he said the DON came in to his room about four months ago when he was a lot heavier and unable to wipe himself. She came in with about six of her cohorts to intimidate him to try to get him to use a wiping device on a long handle. It humiliated and embarrassed him. He said he had been afraid to say anything for fear of repercussions because he had nowhere else to go. 3. Staff Interviews In an interview on 4/16/18 at 2:13 p.m., the staff development coordinator (SDC) said the last dignity inservice was conducted (4/14 and 4/15/18) this past weekend and prior to that, an inservice was conducted on 11/27/17 under resident rights, abuse and neglect. In an interview on 4/19/18 at 9:08 a.m., with certified nurse aide (CNA) #1,she said after the NHA came in February, (YEAR), the atmosphere with residents changed. She said the NHA was not very personable with the residents and the CNA said she had never seen her wanting to interact with the residents. She further said the NHA's personality did not make one comfortable approaching her. In an interview on 4/19/18 9:28 a.m., CNA #6 said one time she was out with the residents that smoked and they complained about the NHA and the many changes she had made and they could not smoke like they used to, could not feed the cat, could not do this, could not do that. She said the DON's attitude was accusatory and condescending; she walked around with the I'm in authority attitude. H. Resident #26 Resident #26 was interviewed on 4/19/18 at 11:56 a.m. The resident said he had concerns with how the DON approached him, specifically, he said the DON was mean to him. The resident said each time the DON approached him felt like it was a sneak attack. The resident said one example of the DON having such an approach was when he had been out of the building visiting a friend for a few nights. The resident had told his medication nurse about his trip and had obtained his scheduled medications for the duration of his time out of the building. The resident felt this was sufficient notification that he would be out of the building and he was unaware of any expectation of additional notice. The resident said upon his return to the facility, the DON confronted him in an accusatory and rude manner related to him not signing out. The resident said the DON was not interested in his explanation. The resident said the DON's approach made him feel like was being treated like a child. I. Resident #72 Resident #72, age 63, was admitted on [DATE] with [DIAGNOSES REDACTED]. He was dependent on a wheelchair for mobility. According to the 4/18/18 MDS, quarterly review assessment, the resident's BIMS score was 15 out of 15 which indicated no cognitive impairment. The mood assessment indicated no depressive symptoms. He did not have hallucinations or delusions indicating no [MEDICAL CONDITION], had no behavioral symptoms and did not reject care. a. Allegation medication discontinued as punishment Resident #72 was interviewed on 4/16/18 at 4:02 p.m. He stated a few months ago the DON accused him of using heroin and called the physician assistant (PA) and had his pain medications discontinued. He denied using heroin and said the DON took his [MEDICATION NAME] and [MEDICATION NAME] pain medication for no reason and without any proof of illegal drug use; he said the facility did not do a drug test on him. He stated after that happened, he started going to a pain clinic and the doctor there restarted his [MEDICATION NAME] and [MEDICATION NAME]. He felt he was punished by having his pain medication taken away for no reason. Review of the resident's record revealed the PA wrote a telephone order on 11/27/17 to discontinue [MEDICATION NAME]([MEDICATION NAME]) 30 milligrams (mg) and to administer [MEDICATION NAME] mg every 12 hours for seven days then it was to be discontinued. (The resident's [MEDICATION NAME] had been reduced 11/17/17). There was no documentation from the PA explaining the 11/27/17 order and no reassessment by the PA or facility staff of the resident's pain level, or concerns about the resident's use of ordered or illegal pain medications. However, Resident #72's psychological evaluation dated 12/13/17 revealed the resident reported he had significant issues with the medical staff at the facility over accusation of heroin use which prompted cuts to his pain medications. The evaluation documented the resident was unsure how to trust the facility staff at this point. On 4/16/18 at 4:27 p.m. the ADON was interviewed. The ADON stated she had heard there was someone at the facility who told the PA about the resident's heroin use. She said I think we drew blood. The ADON stated she could not find the laboratory results for the drug test. b. Smoking Resident #72's care plan initiated 10/24/17 and revised on 3/7/18 revealed the resident was a safe independent smoker. However, staff were directed to inspect his clothing for holes or other cigarette damage. Staff were to instruct the resident on the facility policy on smoking locations, times, and safety concerns. If the resident was suspected of violating the facility smoking policy, staff were to immediately notify the charge nurse. Resident #72 was interviewed on 4/16/18 at 4:02 p.m. The resident explained he had to be supervised when he went out to smoke because of old holes in his pants. He explained he and the NHA had an argument over it and he was upset about his change in smoking status from independent to supervised and he felt he was being punished for having holes in his pants. Resident #72's psychology visit note dated 3/28/18 revealed he had significant frustration with new administration regarding smoking policy. The note documented the resident stated that during a recent conversation regarding his smoking privileges, he and the NHA began to have a verbal confrontation over the matter. A social services progress note dated 3/28/18 documented the information from the psychology note regarding the above smoking conflict with the NHA. The SSD was aware of the resident ' s frustration and verbal confrontation with the NHA. Review of the resident's progress notes revealed no documentation that the resident exhibited unsafe smoking practices to support the resident's need to be supervised while smoking. Further review revealed no initial or updated smoking assessment in his record. The resident's smoking assessments were requested from the facility on 4/19/18. The facility provided an assessment dated [DATE] (during survey). The assessment was not completed. CNA #5 was interviewed on 4/12/18 at 4:09 a.m. She said as soon as the NHA came in (around (MONTH) (YEAR)) she started changing things. She said the smoking were times changed and independent smokers suddenly became supervised smokers. She said Resident #72 is now a supervised smoker because he had old holes in his pants but she saw no reason for him to be supervised. J. Group interview A group interview with 11 alert and oriented residents selected by the facility was conducted on 4/11/18 at 10:30 a.m. Residents #30, #64, #86, #61, #23, #18, #45, #27, #71, #75, and #31 were present for the meeting. Five of the residents said they had concerns with how the facility administration treated them. Specifically, the residents reported the facility administration did not treat them with respect and dignity. -Resident #61 said the DON and NHA were disrespectful to residents in a meeting held to announce new smoking rules. The resident said meeting was a mess and upset every resident in attendance. Multiple residents voiced agreement with resident #61's description of the treatment provided at the smoking meeting. -Resident #64 said DON and NHA were so rude to the residents at the smoking meeting that residents began walking and wheeling out to get away from the meeting. Resident #61 and Resident #88 agreed that residents were upset exited the smoking meeting before its conclusion. -Resident #30 said another way the facility administration failed to provide residents with respect and dignity was related to room searches. Resident #30 said facility administration would come and look for contraband in resident rooms. -Resident #23 reported it upset her when staff searched her room. Resident #64 said the administration had taken items from Resident #23's room. III. Family and staff interviews A. Family interview A family member, who regularly visited the facility, was interviewed on 4/11/18 at 12:01 p.m. The family member said the NHA and DON and other members of staff were not respectful to residents. The family member said she had heard residents, including her family member, complain of being yelled at and having fingers waved in their faces. The family member said there were occasional issues under the previous NHA, but the current NHA's approach to residents made her concerned for her resident family member's well-being. B. Staff Interviews CNA #16, LPN #3, and RN

Based on interviews and record reviews the facility failed to ensure alleged violations related to abuse and/or mistreatment were timely reported to the State Survey Agency for three (#88, #81, and #64) of ten residents reviewed for abuse concerns out of 46 sample residents. (Cross reference to F600, F607, F610). The facility's failue to timely report alleged violations to the State Survey Agency created an environment for repeat incidents of abuse and/or mistreatment by administrative staff which left residents fearful and intimidated. Cross reference F600, F607 and F610. Findings include: I. Facility Abuse Policy In pertinent part, the facility Abuse and Neglect Prohibition policy, revised (MONTH) (YEAR), read, STATE REPORTING OBLIGATIONS: The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment including injuries of unknown origin, and misappropriation of property to the administrator, State Survey Agency, law enforcement officials and adult protective services where state law provides for jurisdiction in long-term care facilities in accordance with Federal and State law established procedures. II. Residents #88, #81 and #64 - Failure to report A. A review of the State Survey Agency abuse allegation reporting database, conducted on 4/9/18 in preparation for survey, revealed one reported allegation of staff-to-resident abuse in (MONTH) and (MONTH) (YEAR). The one (MONTH) (YEAR) report of staff-to-resident abuse was not consistent with Resident #88, #81, and #64 allegations and/or complaint of mistreatment (see residents interview below). B. Resident #88 1. Resident Interview Resident #88, alert and oriented per 3/29/18 minimum data set (MDS), reported in an interview on 4/10/18 at 3:01 p.m. that in (MONTH) (YEAR), the nursing home administrator (NHA) yelled at him, grabbed his wheelchair, placed him in her office and blocked his attempts to leave. When he finally left the office, the NHA followed him and continued to yell at him in front of residents and staff in the common area. Cross reference to F600 for further details regarding alleged abusive behavior by administrative staff toward Resident #88. 2. Staff Interviews Interviews with staff (licensed practical nurse (LPN) #1, the receptionist, van driver and assistant director of nursing (ADON)) who witnessed the (MONTH) (YEAR) incident between Resident #88 and the NHA confirmed Resident #88's report of the events. Staff interviews further revealed failure by staff to ensure the potentially abusive incident by the NHA was reported and investigated. Staff interviews further revealed other potential incidents of abuse by administrative staff toward Resident #88 and failure by staff to ensure all potential allegations of abuse by administrative staff were reported and investigated Cross reference to F600 for further details by the receptionist, licensed practical nurse (LPN) #1, the van driver and assistant director of nursing (ADON) regarding administrative behavior toward Resident #88. 3. Confirmation of Failure to Report Alleged Abuse The district director of clinical services (DDCS) and consulting nursing home administrator (CNHA) were interviewed on 4/10/18 at 5:52 p.m. The DDCSS and CNHA said there was no investigation of an alleged abusive incident between the NHA and Resident #88. The DDCS and CNHA were interviewed again on 4/16/18 8:05 a.m., regarding their investigation of the (MONTH) (YEAR) incident between the NHA and Resident #88. The DDCS said the facility made its initial report to the State Survey Agency on 4/10/18, which was not timely as the incident occurred in (MONTH) (YEAR). The DDCS acknowledged there were multiple witnesses to the incident between the resident and the NHA and the incident should have been reported to the State Survey Agency the next day. The DDCS said Resident #88's allegation of staff-to-resident abuse was substantiated by their investigation. A review of the initial report to the State Survey Agency regarding the (MONTH) (YEAR) incident involving Resident #88 and the NHA confirmed the report was not timely. The report was made during survey, after the concern was brought to the facility's attention. C. Resident #81 1. Resident status Resident #81, age 65, alert and oriented per 3/29/18 MDS, was admitted on [DATE]. According to the (MONTH) (YEAR) CPO, [DIAGNOSES REDACTED]. 2. Resident interview Resident #81 was interviewed on 4/09/18 at 10:46 a.m. She reported she had been harassed and humiliated by administrative staff. She said one day, during the last week of (MONTH) (YEAR), the NHA entered her room, uninvited with the DON and the Activity Director (AD). Her door was closed because she was partially undressed; her pants were pulled down half way for a dressing change by the therapy staff. -She said the NHA spoke to her in a manner and tone which was not dignified, but rather harassing and demeaning. She said she repeatedly asked the NHA and others to leave her room on this occasion (as well as another with the NHA, SSD, and DON). She said the administrative staff would refuse to leave, and in the instance described above, continued to talk to her in loud and harsh tone and in a demanding manner about money she owed the facility. She said when the administrative staff would refuse to leave her room, it made her angry, and she felt humiliated to the point of tears, degraded, as well as powerless in her own home. Cross reference F600 for further details on the resident's interview 3. Staff interview An interview with the activity assistant (AA) on 4/9/18 at 4:00 p.m. confirmed the Resident #81 confided in her regarding mistreatment by the NHA. The AA confirmed the resident was prevented from going on outings. An interview with physical therapist assistant (PTA #1) on 4/9/18 at 4:25 p.m. confirmed she witnessed the NHA speaking harshly to Resident #81 regarding money owed to the facility. The PTA said the NHA was accompanied by a high ranking nurse. The PTA said she did not report the NHA's mistreatment of [REDACTED]. An interview with PTA #2 on 4/10/18 at approximately 9:00 a.m. confirmed he witnessed the NHA speaking harshly and rudely to Resident #81 regarding money owed to the facility. The PTA said that he had worked with the resident a lot and that every time the NHA was near, her demeanor would change and he saw an increase in anxiety. Interviews on 4/11/18 at 11:01 a.m. with CNAs #7, #17, and #18 confirmed they had overheard the NHA and DON speak harshly and rudely to Resident #81 regarding money they said the resident owed the facility. They also said they were aware the NHA made excuses to prevent the resident going to activity outings. Interviews on 4/12/18 at 4:00ap.m. with CNA #19 revealed Resident #81 had spoken to her about not being allow to go on outings she had signed up for. Interview with RN #4 revealed she had overheard the resident tell the CNAs that she had been approached by the NHA, SSD and DON in a threatening manner that made the resident cry. Staff interviews further revealed other potential incidents of abuse by administrative staff toward Resident #81 and failure by staff to ensure all potential allegations of abuse by administrative staff were reported and investigated. Cross reference F600 for further details on staff's failure to report potential incidents of abuse. 4. There was no evidence the resident's complaint was reported to the State Survey Agency. See above; a review of the State Survey Agency. Review of the State Survey Agency reporting database from (MONTH) to (MONTH) (YEAR), conducted on 4/9/18 in preparation for survey, revealed one reported allegation of staff-to-resident abuse. There was no report of an allegation of threats/mistreatment by the NHA to residents. D. Resident #64 1. Resident status Resident #64, alert and oriented per 3/6/18 MDS, reported the NHA addressed her and other residents with a tone of voice, an attitude, with gestures, and with mannerisms that were bullish, abusive and uncalled for. She said the NHA threatened discharge if residents did not follow the rules and she said she felt punished with the NHA changed her smoking status. She said the NHA's behavior was threatening as well as humiliating, made her feel like a two year old child, and recalled for her a violent family trauma from childhood. She said she had reported administrations mistreatment of [REDACTED]. Cross reference F600 for further details on Resident #64 allegations 2. Record review According to a statement provided by district director of clinical services (DDCS), Resident #64 called the corporate Senior Care Satisfaction line on 3/28/18 at 1:07 p.m. to lodge a complaint about mistreatment of [REDACTED]. The document has the tracking information of the Resident #64's call on the 3/28/18 at 1:07 p.m. from the communication team. There was no evidence the resident's complaint was reported to the State Survey Agency. See above; a review of the State Survey Agency. Review of the State Survey Agency reporting database from (MONTH) to (MONTH) (YEAR), conducted on 4/9/18 in preparation for survey, revealed one reported allegation of staff-to-resident abuse. There was no report of an allegation of threats/mistreatment by the NHA to residents. 3. Staff interviews The DDCS, interviewed on 4/11/18 at 1:20 p.m. said she called the Regional Vice President (RVP) on 4/18/18 and found out there had been no action taken on Resident #64's complaint, including no report to the State Survey Agency. The RVP, interviewed on 4/19/18 at 10:23 a.m. confirmed no action had been taken on the resident's complaint. See F610 for further details. III. Interviews with residents throughout the facility revealed facility failures in having an effective system for identifying and addressing concerns with the administrator and DON resulted in residents feeling mistreated (degraded, unimportant, imprisoned) , frightened and fearful of retaliation (kicked out, sent away). Resident #62 was interviewed on 4/9/18 at 1:55 p.m., and on 4/19/18 at 11:59 a.m. The resident said he had concerns with NHA and DON's conduct. According to the resident, shortly after the NHA's arrival around February, (YEAR), the NHA and DON told residents they did not care if residents stayed there at the facility because they would have a job either way. The resident said the DON was mean and would talk down to him. The resident said the NHA and DON's approaches made him feel like he was in prison and he was being punished for his misfortune and for being sick. The resident said this made him feel degraded and not important. The resident said he was unaware of anyone who could address his concerns with the NHA and DON. The resident said he felt worried for his well-being. Resident #59, alert and oriented per 2/28/18 MDS was interviewed on 4/9/18 at 3:45 p.m. The resident said the NHA, social services director (SSD), ADON and DON talk down to her, like she is zero. She said she feels humiliated when they speak to her like she is a child, or when she is accused of wrongdoing. She said these administrative staff charge in like an army to her room and rake you over the coals, and it scares and frightens her. She said that she did not understand why they all had to come in at once to tell her what she was doing wrong. She said she was afraid to say anything about how she was treated; she did not want anyone to hurt her. A group interview with 11 alert and oriented residents selected by the facility was conducted on 4/11/18 at 10:30 a.m. Residents #30, #64, #86, #61, #23, #18, #45, #27, #71, #75, and #31 were present for the meeting. Eight out of 11 residents reported fear of retaliation by the facility when reporting concerns. Comments from the attendees included: -Resident #30 said the NHA acted like a dictator. She said she worried she would be kicked out if she complained about her treatment. Resident #30 said the recent rule changes at the facility made her feel like the facility was more like a prison and less like her home. Resident #30 said she felt like she lost her right to speech, pursuit of happiness and the right to have someone listen to her concerns. -Resident #31 said he worried if he complained the NHA would retaliate by making more unfavorable changes to the facility rules. Other residents in the group voiced agreement with this statement. -Resident #64 said she had tried to talk to a staff member about concerns and the staff member had them move to a place they could not be overheard. Resident #64 said the NHA had told the residents, These are the rules. Follow them or leave. The resident said this statement made her afraid she was going to get sent away. Other residents voiced agreement with Resident #64's statement. -Resident #61 said the NHA was not nice. He felt concerned about punishment or retaliation for complaining about changes made at the facility. None of the residents in the group knew who they could go to with their concerns about the NHA.

Based on observations, interviews and record reviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible and that residents received adequate supervision and assistance to prevent accidents. The facility's failures affected 16 of 47 sampled residents (#82, #101, #44, #51, #76, #88, #133, #66, #15, #53, #118, #7, #72, #67, #132, and #49). Specifically: I. Failure to protect residents from resident to resident abuse. A. Resident #133, who had a [DIAGNOSES REDACTED]. pre-admission evaluation given the resident's history, and without effective interventions to ensure the safety of residents from her behaviors. Prior to resident #133's emergent discharge, the facility failed to take steps to protect resident #44, who was dependent, from resident #133's behaviors. Resident #133 entered resident #44's room and removed the call light he required to summon staff. After readmission, resident #133 was documented as going in and out of other residents' rooms and through their belongings, being very anxious and unable to respond to simple commands; the resident entered resident #44's room four times, once during the day and three times at night. The facility failed to implement measures to ensure resident #133's care was individualized and effective and her supervision adequate to protect the other residents in the facility. Residents #44, #132, and #49 expressed resident #133 made them worried and fearful for their safety. B. Residents #51 and #76 exhibited aggressive, violent, and unsafe behavior in the facility common areas. The facility failed to take steps to protect residents, including resident #101, from verbal, physical, and mental abuse by residents #51 and #76. Resident #101 expressed the residents' behaviors distressed him and other residents reported to staff they feared for their safety when residents #51 and #76 acted out. The facility's failure to keep facility residents safe from resident to resident abuse created a situation of immediate jeopardy (IJ) with the potential for serious harm. II. Failure to protect against accident hazards A. Resident #88 eloped and was located 10 miles away from the facility. The facility failed to take steps to ensure resident #88 was protected from harm due to her wandering behavior; the facility failed to thoroughly investigate the incident and failed to implement interventions to prevent further elopements. B. Residents #53, #15, #7, #66, #72 were smokers and resident #67 was observed in the smoking area. The facility failed to ensure these residents were safe while smoking. C. Resident #118 utilized a heating pad. The facility failed to ensure resident #118's use of a heating pad was assessed for safety and its use adequately supervised. D. Medication carts were left unattended. The facility failed to ensure medication carts were secured. The findings include: I. Immediate Jeopardy A. Findings Triggering Immediate Jeopardy - Resident to Resident Abuse Record review and resident interviews conducted on 10/23/15 revealed resident #133 was wandering and entering other residents' rooms and personal space. Facility staff were aware of the resident's behaviors and effective interventions were not in place to assure residents of their safety. Interviews with residents #44, #132, and #49 revealed they were fearful for their safety and well being. Interviews with staff and observation of resident #133 revealed she was permitted to wander freely throughout the facility with no additional monitoring or care. Record review revealed the resident was discharged from the facility for behaviors on 10/8/15, and readmitted on [DATE] with the only change in her care being the use of Neurontin (an analgesic pain medication used for behaviors). The facility was aware of the resident's behaviors on 10/8/15 when she was initially discharged and readmitted the resident without having a clinical team reassess the resident to determine if she was appropriate for placement in the facility. On readmission to the facility, staff again were aware of the resident's continued behaviors; however, there were no interventions put in place to keep the resident and other residents safe, creating a situation of immediate jeopardy. B. Notification of Immediate Jeopardy Observations, interviews and record review revealed the facility failed to develop and implement interventions and safety measures related to resident #133's known behaviors which made residents fearful for their safety. The facility's failures were discussed with the consultants (Conslt #4, and Conslt #5) from 2:00 p.m. to 2:45 p.m. on 10/23/15. At 3:05 p.m. they were informed that the failures created a situation of immediate jeopardy with the potential for serious harm. C. Plan to Remove Immediate Jeopardy The facility's second plan to remove immediate jeopardy was submitted on 10/23/15 at 6:15 p.m. The plan read: (The facility) respectfully submits this plan of action to abate the allegations of immediate jeopardy identified on October 23, 2015. Residents living in (the facility) have the potential to be affected by this alleged deficient practice. Effective immediately, the identified wandering resident (#133) has been discharged from the center to an appropriate facility to meet her need(s) and will not be readmitted . The resident, staff, Medical Director attending physician and the staff at (the accepting emergency room ) were informed that the resident will not be readmitted to (the facility). All staff currently working at Aspen Living Center have been educated that when they see, hear or are made aware of an allegation of abuse or neglect or any resident concern around safety and or fear, they are to first make sure all residents are safe in any situation then report to the administrator. Remaining staff will be re-educated on the same process before they work another shift. Social Services met with the identified residents that alleged they were fearful of said resident. Social services informed them that the identified resident has been discharged and would not return that they are safe. Each resident responded to the social services director that they felt better and had no other fear. The Social Services Director will address the residents in the next resident council on the facility's process in reporting concerns in particular fear of other residents. The admissions team has been re-educated on the facility's admission process in where they will follow the CF AST guidelines where residents with a history of wandering or elopement, or aggressive behaviors will be brought to the clinical team prior to accepting the resident to (the facility). The administrator and or designee will review incident accident reports, concern forms, 24 hour report and the clinical dashboard in (the electronic medical records system) in each morning meeting to identify any resident to resident concerns. The administrator will bring all concerns to QA (quality assurance) weekly for one month then monthly for 3 (three) months and then quarterly or as needed to review all outcomes and applicable action plans. D. Removal of Immediate Jeopardy The facility's plan to abate Immediate Jeopardy was accepted on October 23, 2015 at 6:20 p.m. and the immediate jeopardy removed. However, deficient practice remained at a G level, actual harm that is isolated. II. Resident to Resident Abuse A. Resident #133 - Facility Failure to Protect Residents from Resident #133's Behaviors 1. Resident Status Resident #133 was a [AGE] year old admitted initially on 10/5/15, discharged to the hospital on [DATE], emergently discharged [DATE], and readmitted from a behavioral health facility on 10/20/15. According to her face sheet, her [DIAGNOSES REDACTED]. The only minimum data set (MDS) assessment available was dated 10/8/15. It noted the resident had impaired decision making skills and behaviors that were directed towards others which occurred daily. It also noted she wandered daily. A care plan for wandering, dated 10/9/15 and revised on 10/13/15, documented: .tends to wander up and down the hall, responding to external stimuli. She touches the items on the wall, at times may take something off the wall with her, or she just might admire it and feel it. This behavior makes peers uncomfortable, putting her at risk for abuse. -The interventions were, Positive reinforcement of desired behaviors, psychotropic medications as ordered, and redirection. The care plan did not describe or detail the nature of the positive reinforcement staff were to employ. The care plan did not address the resident's supervision needs, although see below, the nursing notes documented the resident required constant supervision. The care plan was not updated on the resident's readmission (10/20/15) with guidance to staff on how to address the resident's behaviors. 2. Record Review - Initial stay at the Facility 10/5/15 to 10/8/15 a. Review of the documentation from the discharging facility (admission paperwork for the facility) a discharge disposition noted, Psych Unit/ hospital. The neurological assessment comment read, Confused, possibly having visual and auditory hallucinations, patient restless, talking to self, difficulty falling (sic) directions. b. Review of the nursing notes revealed: 10/5/15: The resident arrived via w/c (wheelchair) alert to name, extremely confused cannot answer questions, easily distracted, can feed self, incontinent of b/b (bowel and bladder), ambulates with unsteady gait, requires constant supervision, unable to sign consents, numerous calls made to son, no response, resident has multiple skin tears about arms, excoriated buttocks. 10/6/15: .Woke up around 0400 (4:00 a.m.). Respirations regular and unlabored. Resident sitting on side of bed carrying on incomprehensible conversation with her water pitcher and comb, occasionally pointing to the wall and ceiling while talking. Made no eye contact with me, did not respond to me calling her name. Refuse to have her VS (vital signs) taken. Safety measures in place, bed in lowest functional position, mat at bedside, wander guard on. Report given to oncoming nurse. 10/7/15: This res (resident) has been very busy, all eve (evening) shift. Going in and out of res rooms, making several attempts to get out of facility. At about 1730 (5:30 p.m.) res was seen going out hall 6 door running, Admin (administration) followed and returned res back inside after she had slipped and fell on the sidewalk. Elbow skintear covered, res continued to exit seek the res (sic) of the eve. Unable to redirect. Frequent visual checks all eve. 10/8/15 at 7:55 p.m.: Resident sent to ER for evaluate and treat r/t (related to) hallucinations both auditory and visual: Continuous elopements from facility: To have medical work up and psych evaluation. c. Review of the only social services note from the resident's initial stay was dated 10/8/15 at 7:33 a.m. noted: .with a dx (diagnosis) of unspecified dementia with behavioral disturbances and dysphagia. She is ambulatory and able to communicate, however, most of her communication is in word salad. Writer talked with (adult protective services (APS) representative) who came out yesterday to help assess resident for needs. She is sending a doctor to come in and do a neuropsych evaluation. Writer did public aid application for resident, and (APS) took it with to push the application process through quicker. (Resident) has a tendency to constantly move when awake, walking up and down the halls almost constantly. She does let staff assist her with her ADL (activities of daily living) care. She eats with her hands, even when cued to use her utensils. Writer unable to complete (cognitive assessments) with resident as a result of her current mental status. Staff redirects her often due to the current mental status; trying different things to see if we can find something she enjoys. d. Behavioral health facility documentation (resident stay 10/8/15 - 10/20/15) The resident was emergently discharged to a behavioral health facility on 10/8/15. Review of the behavioral health facility's admission documentation revealed the following behavioral health note: Spoke with (facility) .the Director of Nursing (DON) noted that the patient had walked into another patient's room and put the call light around her neck and dancing in the room. She also reported patient had swung at a staff member and attempted to bite an EMS (emergency medical services) staff member. (Facility) noted that they have little history on the patient and believe there may be a mental health history with psychosis more so than dementia. The mental status exam conducted at the behavioral health facility, dated 10/12/15, noted the resident was euphoric, irritable, angry, anxious, paranoid with delusions and obsessions. 3. Record Review - Readmission to Facility on 10/20/15 to Discharge on 10/23/15 a. Review of nursing notes revealed in their entirety: 10/20/15 at 9:25 p.m.: This res arrived via BEo (sic) at 1800 (6:00 p.m.), very anxious and unable to respond to simple commands. Has spent this shift walking in and out of other res rooms, has been found going thru other res belongings, Unable to redirect this res, multiple attempts by multiple staff. Res has no concept of personal space or no (sic). This res was seen in the dining room at evening bingo with her hands on a residents (sic) chair and tried to pull it away, with the res in it. This res then stood up and grabbed her cane and as going to hit this res and was intercepted by staff. This res has been one-one for most of this shift. 10/20/15 at 9:48 p.m.: Wandergaurd was placed on left ankle at 1830 (6:30 p.m.) due to res constant wandering and pushing and pulling on any and all doors. 10/23/15 at 4:25 p.m.: Received order from (nurse practitioner) to transfer resident to (sic) ER for evaluation and treatment. b. Record review revealed resident #133 was readmitted [DATE] with a new medication, Neurontin 300 mg PRN (as needed) for anxiety/agitation. The resident was noted as receiving Neurontin 300 mg PRN (as needed) once on 10/21/15 for anxiety/agitation, once on 10/22/15, and once on 10/23/15 (noted as ineffective). c. An incident form referring to resident #133 was found during record review of resident #132's chart. (The form did not involve resident #132 but was mistakenly placed in the wrong chart.) The incident form was dated 10/21/15 and noted It was reported to this nurse that patient took another pts jacket and was walking around when the other patient tapped (resident #133's) upper area with cane no injury noted no bruising noted. There was no follow up or assessment found regarding the incident. d. The sole social services progress note was written after the order to send the resident to theER on [DATE]. At 4:36 p.m. the social services director (SSD) noted, Writer sat with (resident) today as she was wandering through the halls more than she had been since her return from the hospital. Writer redirected her from peers rooms, and offered her something to drink on numerous occasions. She is confused, but shows no signs of aggressive behaviors. She is being transported to the hospital and staff sat with her until the paramedics arrived. e. A telephone order was written on 10/23/15 at 3:30 p.m. ordering, Transfer resident to ER for eval/clearance for psych hospitalization . Resident is danger to self and others. 4. Observations of resident #133 On 10/23/15 resident #133 was observed walking down the 300 hall. She was talking to herself and wringing her hands. On 10/23/15 the resident was observed pacing down the 300 all. When asked her name, she was able to clearly state her name, then she began making loud noises and stating, tutty fruity, and clapping. She held the arm of the surveyor and walked down the hall and said they had to get him in, while leading the surveyor. After a few steps she clapped and turned around and walked the opposite direction. On 10/23/15 at 2:00 p.m. the resident was observed pushing on the locked door at the end of the hall and pushing the buttons on the key pad. She turned around at 2:03 p.m. and began walking up the hall. She said hello and when asked how she was doing, she began to say words that were unrecognizable. She was then observed walking over to the nurses ' cart where she grabbed a metal container filled with ice and pudding and began banging it loudly on the top of the medication cart, saying other unrecognizable words. Two staff members approached the resident and asked the resident to walk with them and stated we will get you some pudding. 5. Resident interviews - Fear of resident #133 a. Resident #44 Resident #44, age 52, entered the facility on 3/23/15. The facility face sheet indicated the resident admitted with [DIAGNOSES REDACTED]. The 9/14/15 MDS revealed the resident's cognition was moderately impaired with a BIMS score of 12. Section G (Functional Status) indicated the resident had limited range of motion of upper and lower extremities to both sides. On 10/6/15 at 3:26 p.m., resident #44 was interviewed. He reported because of his ALS and MS, he was dependent on someone to assist him with all cares. The resident stated he was not able to move his arms or legs; he needed total assistance. He said he had a touch pad call light to alert staff when assistance was needed. (1) Initial allegation of unexpected, potentially unsafe behavior in resident #44's room involving resident #133. On 10/08/15 at 4:01 p.m., resident #44 said the other night a female resident, resident #133, with known behaviors entered his room unexpectedly and uninvited while he was in bed, took his call light, wrapped the cord around her neck and almost knocked over his large flat screen television. The resident stated he was scared the resident was going to jump into his bed and he was unable to do anything to help himself. He stated there was another resident who entered his room when he was sleeping at times and would stare at him. He stated it was creepy to see a resident staring at him. The resident's roommate, resident #101, who was alert and oriented, was interviewed at 4:10 p.m. Resident #101 stated he reported the above incident to the evening nurse (LPN #3). He stated the uninvited resident (resident #133) also walked in on him while he was urinating in the restroom and entered another person ' s room afterward. Resident #101 stated no one has spoken to him about the incident and what he had witnessed involving resident #44. Staff Interviews revealed the incident involving resident #44 and resident #133 had not been reported to administration as of 10/8/15, and therefore, no steps had been taken to address resident #44's concern for his safety. On 10/8/15 at approximately 4:20 p.m., conslt #1 and conslt #2 were informed of the incident reported by resident #44 and #101. Conslt #1 stated she was not aware of the incident and would follow-up. Documentation regarding the incident was requested. On 10/8/15 at approximately 4:45 p.m., conslt #3 stated she was not aware of an incident involving resident #133 and resident #44. Conslt #3 stated the resident's degree of ALS prevented him from moving his extremities. She stated she would look into an intervention to allow the resident to feel safe and protected from individuals entering his room. On 10/9/15 at 3:45 p.m., conslt #1 provided a copy of a incident/accident report dated 10/6/15. The conslt reported the incident report was a late entry and was actually completed on 10/9/15 although the event occurred on 10/6/15. The conslt stated the investigation did not take place until 10/8/15 after the facility became aware of the incident. Cross reference F225; the facility investigation failed to reveal interventions were offered or planned to address the resident's safety concerns and was neither a complete nor thorough investigation of the incident and how the facility planned to prevent further incidents from occurring. (2) Subsequent allegations of unexpected, potentially unsafe behavior in resident #44's room involving resident #133 Resident #44, was interviewed on 10/23/15 at 12:57 p.m. He reported resident #133 had come into his room four times the day before, once during the day and three times at night. He reported staff would come in and try to get her out of the room, but he would frequently have to wait a long time because they were understaffed. He reported the resident would come into his room and yell and scream and say nonsense. He reported he had witnessed the resident swinging at staff when they had tried to get her out of his room and it made him nervous. He stated, I have seen her get in a fight with another resident, I have seen her run around and hide, grab stuff off the walls, yell and say nonsense and go into other residents' rooms. When she came into my room I yelled get out and started pounding on the call light. She started coming towards me and I was scared. Certified nurse aide (CNA) #21, who had worked the previous night on resident #44's hall, was interviewed on 10/23/15 at 9:18 p.m. He reported he was aware of a female resident who went into other residents' rooms throughout the facility who lived on the next hall. He reported he had not seen that resident on resident #44's hall the night before. b. Resident #132 Resident #132, the roommate of resident #133, was an [AGE] year old admitted to the facility on [DATE]. According to her face sheet her [DIAGNOSES REDACTED]. The resident's record revealed she had been admitted to hospice care at the facility. Observation of the resident on 10/23/15 at 1:46 p.m. revealed her daughter was at her bedside and the resident was easily understood. The daughter and resident stated the roommate (#133) was constantly talking to herself and wandering into resident #132's space. The daughter stated the facility had said they were waiting for alternate placement for resident #133 and they would be transferring her out soon. The resident stated that her roommate had not tried to hurt her that she was aware of; however, her roommate's behavior had been so odd the resident was worried something 'bad' may happen. The daughter and resident stated the facility had placed the bedside table in the high position to block the roommate (resident #133) from getting to the resident, and a CNA had placed a wheelchair against the bathroom door to prevent another wandering resident from entering through the shared bathroom. The daughter stated the hospice nurse had been in the room and had to redirect resident #133 away from her mother that day. c. Resident #49 On 10/23/15 at 1:54 p.m. resident #49's room was approached and the door was found to be blocked from the inside with a chair. After knocking several times, the resident's roommate moved the chair from the doorway and opened the door. Resident #49 stated the chair was placed in the doorway to prevent that woman (resident #133) from coming into the residents' room. Resident #49 stated the night before last she heard resident #133 in the hall and resident #133 came into the residents' room and yelled, Does anyone want to get up, want to know about? The resident stated she had reported the issue to the customer service coordinator (CSC) the previous day. She had given all good reviews about the facility, but told the CSC they needed to work on resident safety. The resident had not heard any response to her concern about safety, and she stated she was afraid of resident #133 and wished they would do something. The resident stated the staff had seen resident #133 come up to her when she was at a medication cart receiving her medications from the nurse. Resident #133 started going through her bag that she had on her walker and when she told her to stop, resident #133, Threw her chest out, it was aggressive. The nurse had redirected resident #133, but she was still afraid. In an interview on 10/23/15 at 3:28 p.m. with the CSC, Nursing Home Administrator (NHA), and assistant director of nursing (ADON), the CSC responded resident #49 had recently completed a satisfaction survey and the resident had not shared any concerns with her but had given all positive responses to the interview. She said the resident had reported the other night someone had popped her head in and said, are we ready to get up in here. Resident #49 had stated that it startled her. The CSC had not reported that to anyone else. 7. Facility failure to assess resident #133 for appropriate placement and safety prior to readmission 10/20/15 and failure to implement new interventions once readmitted . An interview was conducted on 10/23/15 at 3:28 p.m. with the NHA, CSC and At DON. -The CSC stated she had received a call (10/20/15) from the behavioral health hospital where resident #133 had been admitted on [DATE], asking if they could readmit the resident. The behavioral health hospital stated the resident was ready to come back to the facility. The CSC said the SSD had done the resident assessment. -The NHA stated the SSD sent him a text message that the resident seemed to be appropriate to return to the facility. There had been no additional discussion about the resident's behaviors; at that point, the appropriateness of the resident's readmission would have been referred to clinical staff. The NHA stated the director of nursing (DON) would be the appropriate one to talk to. An interview with the DON on 10/23/15 at 8:31 p.m. revealed she had been on vacation when the resident was readmitted . She said that usually, she would be the one who would review the clinical piece of an admission; however, with her gone, it would have fallen to administration to review the admission. She stated she would not have taken resident #133 back because on her first admission, the resident had needed calming down immediately; she said she had sat in the dining area talking to the resident one on one and calming her down, and the resident had put a checker piece in her mouth which the DON had to get the resident to spit out. She stated that she was not made aware of the incident on 10/21/15 (see documentation post readmission above) and had not seen the incident form until it was discovered during survey. An interview with the SSD on 10/23/15 revealed she had gone to the hospital and observed the resident prior to her readmission. The resident had not exhibited behaviors when she was observed in the hospital. She said the hospital had added Neurontin to the resident's drug regimen and the first couple of days, the resident was back she still appeared sedated; however, she then started getting back into the behaviors. -The SSD stated she was not aware of the resident being on a one to one (see 10/20/15 readmission note above) and when she had interviewed the resident identified in the incident report with the cane, she stated the resident had not been hit. -She stated staff would talk to her if they needed to put a resident on a one to one, but if they were having concerns with a resident's behavior when she was not there, they could put the concerns on a concern form and she would then figure out a plan of action. Review of the facility's CF AST form (facility guidelines for admission of residents with a history of wandering or elopement, or aggressive behaviors - see abatement plan above) revealed in Section II, that a nursing consult would be needed based on behaviors and medications. -There was no evidence this form had been completed on resident #133's readmission 10/20/15, although it is a part of the facility's readmission process. -Given the resident's history, completion prior to resident #133's readmission would have triggered further screening and an interdisciplinary team discussion about the facility's ability to meet the resident's needs, as well as the safety needs of other facility residents. B. Resident #51 and #76 Interviews and record review revealed residents #51, #76, exhibited physically and verbally aggressive behaviors in the common areas that had the potential to physically harm residents and staff and caused residents to fear for their safety. 1. Allegations of resident to resident and staff abuse involving resident #76 and resident #51 and failure of the facility to protect residents from such abuse. a. Resident #82 Resident #82 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 8/4/15, indicated the resident was cognitively intact, as evidenced by a score of 15 out of 15 on the brief interview for mental status (BIMS) exam. Resident #82 was interviewed on 10/6/15 at 5:50 p.m When asked about concerns or problems with a roommate or any other residents, the resident stated, It's (resident #51). Residents are fearful of him. He can respond in a logical way, but other times he just goes off .He tends to target women. I've seen his handprint on staff . The resident continued, A few months back he wanted to go out so I slipped past him and went out the door. I couldn't get back in because he was swinging the mailbox .It was such a frightening moment .I don't have a lock on my door. I don ' t feel safe . The resident verbalized she wrote a long letter on 7/15/15 about this incident and how it made her fearful, made a copy of it, and then put the copy of the letter into the grievance box which was located outside the administrator's office. The resident showed the letter to this surveyor. The resident stated, They never got back to me. b. Resident #101, age 55, admitted into the facility on [DATE]. He readmitted again on 8/29/15 from the hospital. The resident ' s electronic medical record revealed current [DIAGNOSES REDACTED]. The 7/13/15 Minimum Data Set (MDS) assessment showed the resident's cognition was intact with a brief interview for mental status (BIMS) score of 15. Section C (Cognitive Patterns) revealed the resident did not have any behaviors related to inattention, disorganized thinking, or altered level of consciousness. On 10/6/15 at 3:09 p.m., resident #101 was interviewed. He stated there were times in the facility he felt mentally and emotionally distressed. He stated there were two residents in the facility with known unsafe behaviors. The resident stated one resident (#76) routinely threw items in the dining room with residents present when she was upset. He stated when the resident was in a bad mood, residents had to protect themselves because the staff allowed the resident to act out instead of dealing with the resident's behaviors. The resident further shared there was a second resident (#51) who grabbed the fire extinguisher in the main dining room and he witnessed the resident hit people. He stated the resident grabbed a facility mailbox to use as a weapon. The resident stated he reported these events to staff. He also expressed times when he had to intervene between resident altercations when staff was not available or would not interv

Based on observation, interview, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Specifically, the facility failed to ensure that sufficient nursing staff was in place to meet resident needs related to dignity, choices, accommodation of needs, pain management, pressure ulcers, accident prevention, toileting, grooming and hygiene, behavioral health concerns, and positioning. The lack of sufficient nursing staff contributed to negative resident outcomes; residents expressed fear for their safety, severe pain, incontinence, and sense of worthlessness, as well as the development of additional pressure ulcers for one resident. Cross reference F225, F241, F242, F246, F309, F312, F314, F323, F329, and F441 The findings include: 1. Observations, record review, and interviews with residents and staff, from 10/6/15 to 10/23/15, revealed insufficient nursing staff to maintain the quality of care and quality of life expected and necessary for facility residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being Cross-reference F225G - Failure of nursing staff to timely report, thoroughly investigate and take steps to protect residents from abuse, mistreatment, neglect and exploitation (MANE). Failure of the facility to timely and thoroughly investigate violations involving MANE and take steps to protect residents from MANE contributed to residents fearing for their safety. Cross-reference F241G - Failure of nursing staff to treat residents in a dignified and respectful manner. This failure contributed to one resident feeling worthless, frustrated, angered, embarrassed and dirty when she sat in a wet incontinence brief. Cross-reference F242D - Failure of nursing staff to honor resident preferences regarding bathing. Cross-reference F246D - Failure of nursing staff to ensure resident access to call lights. Cross-reference F309H - Failure of nursing staff to effectively address residents' pain, behaviors, positioning, as well as a failure to coordinate hospice services. These failures contributed to residents fearful for their safety due to, at times, aggressive and violent resident behaviors, residents experiencing severe pain, and one resident developing additional pressure ulcers. Cross-reference F312E - Failure of nursing staff to assist dependent residents with activities of daily living (ADLs) including toileting and showers/baths. Cross-reference F314G - Failure of nursing staff to comprehensively assess, monitor and document information on the status of one resident's skin, communicate with the interdisciplinary team (IDT) and re-evaluate planned interventions when the resident's existing ulcer failed to heal and he developed three new ulcers. Cross-reference F323K - Failure of nursing staff to provide an environment as free from accident hazards as possible, including: A failure to provide residents a safe environment from aggressive, unsafe and, at times, violent behaviors by other residents that contributed to residents' fear for their safety; a failure to prevent resident elopement; and a failure to prevent injuries from heating devices and unsafe smoking. Cross-reference F329D - Failure of nursing staff to prevent the administration of unnecessary medications Cross-reference F441F - Failure of nursing staff to maintain an infection control program to prevent the spread of infection. 2. Resident Population The Census and Conditions of Residents provided by the facility on 10/13/15 revealed: -The census was 93 residents. -75 residents required assistance with bathing. -67 residents required assistance with dressing. -80 residents required assistance with transfers. -83 required assistance with toileting. -74 required assistance with eating. -40 residents had a [DIAGNOSES REDACTED]. -57 residents had a psychiatric diagnosis -42 residents had behavioral health needs. -57 residents were occasionally or frequently incontinent of bladder. -36 residents were occasionally or frequently incontinent of bowel. -57 residents were in a chair all or most of the time. 3. Planned and Actual Staffing Patterns a. Nurses A review of the September 2015 nurse schedules for the building revealed: -Five nurses were scheduled during the day shift. -Five nurses were scheduled during the evening shift. -Three nurses were scheduled during the night shift. Review of the actual staffing for September 2015 revealed the facility did not meet planned nurse staffing on 14 days. b. Certified Nurse Aides (CNAs) A review of the September 2015 CNA schedule showed the facility planned: -Nine CNAs during the day shift. -Nine CNAs during the evening shift. -Four CNAs during the night shift. Review of the actual staffing for September 2015 revealed the facility did not meet planned CNA staffing on four days. 4. Resident Interviews Nine residents, identified by the facility and by cognitive assessment as interviewable, stated during interviews that the facility did not provide sufficient nursing staffing to meet residents' care and services needs in a timely manner. Resident interviews, conducted throughout the facility, revealed the following: On 10/6/15 at 2:00 p.m., resident #60 was interviewed, and was asked if the facility had enough staff to ensure residents received the care they needed without having to wait a long time for assistance. The resident stated, They consider hall 5 and 6 one hall. Hall 5 and 6 have three CNAs. The other halls have two CNAs (each). The girls do the best they can .Some of the nurses will answer the lights but some don't. The girls will ask the nurses, but they will say it's not up to me. I hear a lot of stuff - the girls complaining and no one on the other floor are willing to help them. The resident related that she once waited 40 minutes for assistance. I was in extreme pain - spasms in my legs. They said we had to do that and this, but I'm jumping out of my skin because I'm in so much pain. On 10/6/15 at 2:45 p.m., resident #18 said, They need more CNAs on all the shifts. On the night shift there's one CNA for the 600 hall and one on 500. We all have a lot of problems that take time .They run themselves ragged. The resident verbalized she once waited 45 minutes on the commode - after pressing her call light button - for assistance back to her bed. On 10/6/15 at 3:00 p.m., resident #3 reported she often waited a long time for assistance with going to bed. On 10/6/15 at 3:19 p.m., resident # 101 stated, At night there's not enough staff, and if I was to push the call light, it would be 20 to 30 minutes, and they cut down on nursing and aides - four aides and nurses for the whole building. They say they can do that, but we don't even have a RN (registered nurse) on when there should be an RN in this building. Last week we went without an RN. On 10/6/15 at 3:26 p.m., resident #44 verbalized, They're pretty good but have a hard time because they're understaffed. It sucks having to wait for people. I'm totally dependent and have to wait for someone to pee, sometimes a half hour. On 10/6/15 at 3:40 p.m., resident #122 said, I think they need more girls. You can see it in them. The resident reported she sometimes waited 30 minutes for assistance in the afternoon to be changed or to get up. The resident stated, It makes me feel stinky, dirty. They tell me they were busy in another room. On 10/6/15 at 4:00 p.m., resident #26 reported he had experienced wait times of 30 minutes on all shifts. The resident stated, When I need something, I don't like to push the button during shift change. I try to be considerate. On the third shift there's one CNA. I have a Hoyer lift and they have a long time finding help, so I need to make sure I'm in bed by 10 p.m. before shift change. At home I'm a night owl. On 10/6/15 at 4:55 p.m., resident #82 stated, These halls 5 and 6 are the busiest two halls in the facility. The CNAs don't have time to answer the call lights .I've taken a couple of falls. To be safe I ask for assistance to use the commode. The resident verbalized that one time she had waited 45 minutes for assistance after pressing her call button. On 10/6/15 at 5:00 p.m., resident #28 verbalized that during the evening meal service, No one is here to answer, and I have to catch one going by and yell enough for someone to hear .I train my body to go to the bathroom at prime times when I know someone is around to help me. Last night I waited over two hours for prn (as needed) and break-through (medications) .The button was pressed and they said they would tell the nurse and no one came. On 10/7/15 at 1:00 p.m., resident # 27, who was the resident council president, reported that call light wait times were often brought up by participants of the monthly resident council meetings. The resident stated, They say they're not answering my call light as quickly as they should .A lot of residents have concerns about call lights. 5. Staff Interviews 1. Activities Manager (AM) On 10/7/15 at 1:20 p.m., the AM reported that she had attended the August and September 2015 resident council meetings. The AM shared that at one of the meetings, residents expressed that they were waiting longer for assistance on halls 5 and 6, especially on the weekends when there was just one CNA. The residents were encouraged by other staff members at the meeting to write a statement about this concern. 2. Director of Nursing (DON) On 10/7/15 at 3:20 p.m., an interview with the DON revealed: -Currently (on 10/7/15) the census was 95 residents. -On Hall 2 there were 24 stable long term care residents. Two residents required Hoyer lifts, requiring two staff members for each transfer. -On Hall 3 there were 18 residents with behaviors. Four residents required Hoyer lifts. -On Hall 4 there were 19 younger residents with some behaviors. Two residents required Hoyer lifts. -On Hall 5 there were 19 long term care and overflow rehab residents. Four residents required Hoyer lifts. -On Hall 6 there were 15 rehab residents. Two residents required Hoyer lifts. -The night shift nurse aide (CNA #11), who was scheduled to work on halls 5 and 6, had a caseload of 25 residents. 3. Nurse Aide (CNA #11) On 10/8/15 at 3:30 p.m., CNA #11 verbalized the following: -They (residents) don't like it because it's short-staffed. -I try my best. I have to rush. The other CNAs can't do their (scheduled) rooms here (halls 5 and 6). I say I'll be here as soon as I can. -Last night there were three people screaming on 500. They need someone to stay with them. I can't, so I just keep an eye. The screaming keeps others up. -Skilled (residents) need help to go to the bathroom. -The Hoyer needs two people. 4. On 10/8/15 at 1:06 p.m., an interview with a staff member requesting anonymity for fear of reprisal revealed that s/he was caring for 34 residents. The staff member stated s/he was unable to meet each resident's needs when caring for so many. The staff member stated s/he felt overwhelmed. The staff member stated that s/he would not care for his/her family member in this way. 5. On 10/8/15 at 11:10 a.m., an interview with registered nurse (RN) #4 revealed that she had worked up to 16 days in a row without time off. The RN stated that she was called into to provide coverage as an aide for part of the day shift because they were short today. The RN stated that sometimes she felt burnt-out from working so much and felt like she could not give the care she wanted to. 6. On 10/9/15 at 3:52 p.m. and on 10/13/15 at 4:02 p.m., the DON was interviewed. -The DON revealed that working at the building had been difficult due staffing concerns. She said she had started at the facility on 8/27/15. She said she was having a difficult time keeping up with the demands of the job. -The DON reported that some nursing staff were overworked and were trying their best to keep things together, while other staff needed education. The DON stated there were also staff that needed to be removed, but she could not do that at this time. -The DON stated she did not have an assistant DON (ADON), staff development coordinator, unit manager or any other nurse leader to help her address concerns. The DON stated a new ADON was hired but had not started. 7. Nursing Home Administrator (NHA) On 10/9/15 at 8:35 a.m., an interview with the NHA revealed: -Nights has always been four CNAs. -We're working on getting a unit manager. We had that position but we lost her in July. -The former unit manager was sometimes pulled to the floor. -Unit managers are able to teach and train and observe staff and lay eyes on wounds. 8. Day-Shift Nurse (RN #3) On 10/13/15 at 12:25 p.m., RN#3 stated, We all feel overwhelmed because there's an issue with nursing shortage. It's helpful when there's five nurses, but there's not, so we have to pick up the slack .I hear the CNAs talk all the time about how there should be two on each hall, especially on (halls) 5 and 6 .Residents say the same thing. They say they need more help.

Based on observations, interviews and record review, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically: The resources of the facility were not effectively and efficiently utilized as evidenced by findings that revealed in part: -The facility failed to protect residents from resident to resident abuse. -The facility failed to treat residents with dignity and respect, failed to protect their rights, failed to honor their preferences, and failed to accommodate their needs. -The facility failed to manage residents' pain. -The facility failed to comprehensively assess, monitor, and address resident behaviors, as well as monitoring the effectiveness and necessity of psychopharmacological medications. -The facility failed provide sufficient and qualified nursing staff to ensure residents received the care and services necessary to meet their needs; -The facility failed provide a an environment that was as free from accident hazards as possible. -The facility failed to develop and implement a Quality Assurance program to identify quality deficiencies and to develop effective action plans to address them. Cross-reference F159, F225, F241, F242, F246, F248, F250, F253, F272, F279, F280, F 281, F309, F312, F314, F323, F329, F334, F353, F371, F441, F505, F514, F517, and F520. The findings included: I. Resident Rights Cross reference F159: The facility failed to protect resident funds by notifying residents who were Medicaid participants that their personal funds were approaching the resource limit. II. Resident Behavior and Facility Practice Cross reference F225: The facility failed protect residents from abuse, mistreatment, neglect and exploitation (MANE) by not thoroughly investigating allegations/incidents of potential MANE and taking steps to protect residents during the investigations. This contributed to residents continuing to be fearful for their safety. III. Quality of Life Cross reference F241: The facility failed to treat residents with dignity and respect. This contributed to a resident feeling worthless, angry and frustrated. Cross reference F242: The facility failed to seek and honor resident preferences regarding their life in the facility. Cross reference F246: The facility failed to provide reasonable accommodation of individual resident needs. Cross reference F248: The facility failed to provide individualized activity program to promote a resident's physical, mental and psychosocial well-being. Cross reference F250: The facility failed to provide medically-related social services. Cross reference F253: The facility failed to provide a sanitary, orderly and comfortable environment. IV. Resident Assessment Cross reference F272: The facility failed to complete comprehensive assessments. Cross reference F279: The facility failed to develop comprehensive plan of care. Cross reference F280: The facility failed to review and revise plans of care. Cross reference F281: The facility failed to ensure professional standards of nursing care were followed. V. Quality of Care Cross reference F309: The facility failed to provide care and services to ensure residents' attained and maintained their highest practicable level of physical, mental and psychosocial well-being. Facility failures contributed to residents experiencing severe pain, exhibiting aggressive behaviors that frightened residents, and for one resident whose positioning needs were not addressed, the development of additional pressure ulcers. Cross reference F312: The facility failed to provide assistance to dependent residents with activities of daily living. Cross reference F314: The facility failed to provide treatment and services to prevent and heal pressure ulcers. A resident who entered with one pressure ulcer developed three additional pressure ulcers after admission. Cross reference F323: The facility failed to provide an environment as free from accident hazards as possible. The facility failed to protect residents from abusive resident behaviors which contributed to residents fearing for their safety. The facility further failed to address other accident hazards presented by elopement, smoking, equipment, and unsecured medication carts. Cross reference F329: The facility failed to ensure resident medications regimens were free from unnecessary drugs. Cross reference F334: The facility failed to ensure immunization was discussed/offered to one resident VI. Nursing Services Cross reference F353: The facility failed to provide sufficient nursing staff to meet resident care needs as evidenced by findings that showed residents' need for care and services, as well as their need for safety, were not being met. VII. Dietary Services Cross reference F371: The facility failed to store and serve food in a sanitary manner. VIII. Infection Control Cross reference F441: The facility failed to follow infection control procedures. IX. In addition to the above, the facility failed to ensure the following administrative issues were met: Cross reference F505: The facility failed to ensure laboratory results were promptly reported to the physician. Cross reference F514: The facility failed to ensure clinical records were accurate and complete. Cross reference F517: The facility failed to maintain written, up to date plans and procedures to meet emergencies. Cross reference F520: The facility failed to provide an effective quality assurance system. In summary, over 25 deficiencies were cited during the recertification/ extended survey in multiple regulatory categories affecting resident health, safety and life. One deficiency included findings that placed residents in immediately jeopardy for serious harm (F323K). Two deficiencies included findings of actual harm at a pattern (F309H and F353H). X. Interviews On 10/6/15 an interview with resident #60 revealed that she brought concerns about staffing and other issues to the administration. According to the resident the facility response was to listen. On 10/7/15 at 5:45 p.m., an interview with a member of staff requesting anonymity revealed that s/he has reported concerns to building administration. According to the staff member the administration did not respond to the concerns. On 10/7/15 (time was not noted) an interview with consultant #2 revealed the building's previous administration had caused many of the building's effective staff to leave. By the time the previous administrator was removed, many department heads and other staff had departed. The consultant stated the facility was now in a rebuilding phase because many systems had been lost. On 10/8/15 at 2:32 p.m., an interview with three staff, who requested anonymity, revealed that the facility regularly operated without sufficient staff. The staff felt the administration had not been working to address this problem. According to the staff, they did not have a unit manager or an assistant director of nursing to help with administrative duties and care coordination. On 10/9/15 at 11:09 a.m., an interview with the health information manager (HIM) revealed that she felt the facility did not have effective administration. The HIM stated the previous NHA had been ineffective and had cut so much from staff and services that every other department head and many good staff had left. The HIM stated that she worked to come to meetings with solutions, but that often her suggestions were not considered or implemented. On 10/13/15 at 2:07 p.m., an interview with a staff member requesting anonymity revealed that the administration had done nothing to address staff turnover, which was a major problem for the building. According to the staff member, many competent staff had departed due to the difficult administration. The staff member stated that there was no one in nursing leadership except the Director of Nursing, who was overwhelmed most of the time, to in helping to meet the resident's nursing needs. See F353 for additional resident interviews and F520 for additional administration interviews.

Based on observation, record review, the facility failed to ensure six of 47 sample residents (#44, #3, #56, #133, #51, #26) received the necessary care and services to attain their highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically: -Resident #44: The facility failed to effectively address ongoing pain. Orders and care planned interventions pertaining to the resident's pain were not followed. The facility did not evaluate the effectiveness of the resident's pain medications and interventions either following the administration of pain or during interdisciplinary care conferences. The facility's failures contributed to the resident frequently experiencing severe, unrelieved pain. -Resident #3: The facility failed timely address, through pharmacological and non-pharmacological interventions, the resident's pain which exceeded her acceptable level of pain. Cross reference F241; dignity -Resident #133: The facility failed to adequately assess and address the resident's behaviors of wandering into residents' rooms. The resident's behaviors made residents fearful for their safety. Cross reference F323; accident hazards/resident to resident abuse. -Resident #51: The facility failed to provide necessary care and services to understand and address the resident's aggressive and sometimes violent behaviors that made residents fearful for their safety. Cross reference F225; facility practices and F323; accident hazards/resident to resident and staff abuse. -Resident #26: The facility failed to assess, care plan, and implement pressure relieving strategies to address positioning for the resident who developed three new pressure ulcers after admission. Cross reference F314; pressure ulcers -Resident #56: The facility failed to coordinate with hospice regarding the resident's care needs. The findings include: I. Pain A. Facility Policies 1. Pain Management The facility's Pain Management policy, dated August 2012, read in pertinent part: -Residents will be screened for pain by using the Monthly Summary and the Pain Evaluation Form quarterly, annually, and with a significant change and/or new onset of pain. -Pain intensity and pain relief will be evaluated and re-evaluated at regular intervals. These evaluations will be used by the IDT (interdisciplinary team) to decide the appropriate therapeutic intervention, which may include pharmacological and non-pharmacological techniques. -Additionally, any resident report of inadequate pain control or identified with a new onset of pain, displays new signs or symptoms of pain or identified through the RAI (resident assessment instrument) process will have a full evaluation of the pain conducted using the Pain Evaluation Form. -Following the pain evaluation notify the physician of the findings and document on the Change of Condition / SBAR form. Implement new orders as received. -Each resident identified for pain will have a Pain Management Care Plan. The Care Plan will have individualized interventions related to that resident's individual control of pain management. The Care Plan should include both pharmacological and non-pharmacological pain management interventions. -The pain Management Care Plan with interventions will be updated as indicated and discussed at the IDT stand up meetings, as needed. -The staff will implement the Care Plan, monitor the resident, and administer therapeutic interventions for pain, if ordered. -At any time through the process of Pain Management, the IDT may conduct an At-Risk Review Meeting on the resident, in conjunction with other Risk areas reviewed. IDT referral to Rehab as needed. -If areas for improvement are identified, the Pain Management Program will be reviewed and discussed at the monthly Quality Assurance & Performance Improvement meeting. 2. Care Planning and Care Conference The facility's Care Planning and Care Conference policy, dated January 2012, included the following protocols: -It is vital that care plans address and include the resident's voice, and that evidence is present of his or her involvement in the development and ongoing processes. -The comprehensive MDS (minimum data set) assessment is completed using an interdiscliplinary approach and includes significant input from the resident. Information from the resident regarding his or her needs, desires, and preferences will be a vital part of the care plan development process- from initiation and provision of care to discharge planning. -Care plan review, conduct revisions and updates: as necessary to reflect changes in care and treatment; quarterly; with all comprehensive assessments; and based on resident changes in resident preferences or desires. -Evaluation should include, at minimum: Progress toward goal achievement on or before the target date. Document at minimum in the Progress Notes of the associated discipline; signatures of the participants in the care planning process. Enter on the Care Conference signature sheets. -IDT members are responsible to come to the meeting prepared to discuss resident progress, based on the quarterly progress notes and review of the current care plan problems, goals, and interventions. The IDT signs the Care Conference Attendance Record to validate attendance and files it in the Medical Record under the care plan tab. B. Resident Failures 1. Resident #44 a. Resident Status Resident #44 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly minimum data set assessment, dated 9/14/15, indicated the resident was cognitively intact, as evidenced by a score of 12 out of 15 on the brief interview for mental status exam. The resident required extensive assistance for all activities of daily living. b. Pertinent Physician Orders The October 2015 Order Summary Report included the following physician orders: -(8/24/15) [MEDICATION NAME] Tablet 10-325 mg. Give 1 tablet by mouth every 4 hours as needed for pain. Hold if sedated. -(8/25/15) [MEDICATION NAME] Tablet 10-325 mg. Give 2 tablets by mouth every 4 hours as needed for pain - severe 6-10 pain. -(3/23/15) [MEDICATION NAME] Tablet 600 mg. Give 1 tablet by mouth every 8 hours as needed for pain. -(3/23/15) [MEDICATION NAME] Tablet 1 mg. Give 1 tablet by mouth every 8 hours as needed for anxiety. -(3/23/15) [MEDICATION NAME] Capsule 15 mg. Give 1 capsule by mouth every 24 hours as needed for [MEDICAL CONDITION]. -(9/23/15) [MEDICATION NAME] Tablet 10 mg. Give 1 tablet by mouth one time a day for Depression until 10/8/15. Increase to 20 mg after two weeks. -(10/9/15) [MEDICATION NAME] Tablet 20 mg. Give 1 tablet by mouth one time a day for Depression. -(5/5/15) Pain assessment each shift. -(7/15/15) Therapy to place hot and cold packs as needed for muscle spasms. -(8/26/15) Get soft cervical collar. Wear during the day. -(9/23/15) A telephone order read, Refer pt to pain clinic. c. Care Plans Record review revealed the resident was care planned for alteration in musculoskeletal status, pain and pain medication. (1) Alteration in Musculoskeletal Status, last revised on 4/11/15, read, in pertinent part: -Focus: Resident has an alteration in musculoskeletal status r/t (related to) progression of disease process. -Goal: Resident will have reduced pain or at a level of discomfort acceptable to him through the review date . -Interventions: .Give [MEDICATION NAME] as ordered by the physician. Observe and document for side effects and effectiveness; Heat/cold applications as ordered and as tolerated . (2) Pain The resident's Pain care plan, last revised on 4/11/15, read, in pertinent part: -Focus: Resident has chronic pain r/t his progression of disease process. -Goal: Resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. -Interventions: .Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; .Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition; .Notify physician if interventions are unsuccessful .; Provide non-pharmacological interventions: hot/cold pack application, positioning/support, assistive devices/braces, exercise program, stretching exercises, massage, recreational therapy, activity programming, music, aromatherapy, meditation; Therapy referral as indicated. (3) Pain Medication The resident's Pain Medication care plan, last revised on 4/11/15, read as follows: -Focus: Resident receives pain medication therapy r/t chronic pain. -Goal: Resident will have reduced pain by next review date with current interventions in place. -Interventions: Administer [MEDICATION NAME] medications as ordered by physician; observe/document side effects and effectiveness q(every) shift; Ask physician to review medication if side effects persist. Notify physician for any unrelieved pain . d. Medication and Treatment Administration Records Review of medication and treatment records revealed the resident experienced severe pain at times and frequently received PRN pain medication. Nonpharmacological interventions ordered (heat/cold packs, soft cervical collar) were not implemented to compliment medication management of the resident's pain. (1) September 2015 The September treatment administration record (TAR) indicated the following: -On the day shift, the resident's pain level was severe (6 - 10) on 13 out of 30 days. -On the evening shift, the resident's pain level was severe (6 - 10) on 18 out of 30 days. -The resident did not receive the following order on any day in September: Therapy to place hot and cold packs as needed every 2 hours for muscle spasms. -The order to wear a soft cervical collar during the day (8/24/15) was not indicated on the TAR. The September Medication Administration Record [REDACTED] -On the day shift, the resident received two PRN [MEDICATION NAME] tablets on 29 out of 30 days, and an additional one PRN [MEDICATION NAME] tablet on seven out of 30 days. The effectiveness of the medication was not documented. -On the evening shift, the resident received two PRN [MEDICATION NAME] tablets on 17 out of 30 days, and an additional PRN [MEDICATION NAME] on seven out of 30 days. The effectiveness of the medication was not documented. (2) October 2015 The October TAR (10/1/15 through 10/9/15) indicated the following: -On the day shift, the resident's pain level was severe (6-9) on 2 out of 9 days. -On the evening shift, the resident's pain level was severe (6-9) on 5 out of 9 days. -The resident did not receive the following order on any day in October: Therapy to place hot and cold packs as needed every 2 hours for muscle spasms. -The order to wear a soft cervical collar during the day (8/24/15) was not indicated on the TAR. The October MAR (10/1/15 through 10/9/15) indicated the following: -On the day shift, the resident received two PRN [MEDICATION NAME] tablets on 8 out of 9 days. The effectiveness of the medication was not documented. -On the evening shift, the resident received two PRN [MEDICATION NAME] tablets on 8 out of 9 days. The effectiveness of the medication was not documented. e. Care Conferences Review of the resident's record showed there one care conference since admission, which occurred on 6/30/15. The Care Conference Note, dated 7/3/15, read, IDT met for residents quarterly C.C. (care conference) on 6/30/15. Resident was invited but declined at this time. Resident is on mechanical soft and is at 95% intake. Resident weight is 154. Resident often stays in his room. Resident has recently been moved to different room and resident reports he has no issues with room change at this time. Resident's placement plan is for LTC (long term care). The note did not indicate which staff members participated in the care conference. There was no indication an attempt was made to reschedule the care conference to accommodate the resident's scheduling preference. There was no evidence the resident's pain was discussed among IDT members and with the resident, or that interventions were reviewed. The resident's care plans were not updated. f. Nurses' Notes The resident's record included the following Nurses' Notes, from 9/29/15 through 10/9/15, documenting the resident was experiencing unrelieved, severe pain almost daily. Specifically: -(9/29/15, 6:31 a.m.)-Pt (patient) complains of different type of pain - severe burning along back. Admin 2 narco po (by mouth). -(9/29/15, 12:00 p.m.)- c/o (complains of) neck and shoulder pain 9/10. -(9/30/15, 5:18 a.m.)- Pt complains of sharp pain in back up neck 10/10 request pain med admin 2 narco 10/315 will continue to monitor -(9/30/15, 10:48 a.m.)- c/o pain neck and shoulder 9/10 -(9/30/15, 9:23 p.m.)- Resident states I'm still in a lot of pain. -(10/1/15, 4:42 a.m.) - Pt complains of burning type pain shoulder, back and neck admin 2 narco . -(10/1/15, 10:52 a.m.)- c/o neck and shoulder pain 9/10 -(10/2/15, 5:22 a.m.)- Pt complains of sharp burning pain down back and across shoulders and neck. admin 2 narco . -(10/4/15, 4:45 a.m.) - Resident states pain to neck and back -(10/6/15, 6:05 a.m.)- Pt complains of sharp pain neck shoulders and back admin 2 narco . -(10/6/15, 7:15 a.m.) - For the past several weeks it seems pt pain has changed in intensity pt says it is sharp stabbing often radiating from skull to spine pt says he does get some relief with meds . -(10/7/15, 6:35 a.m.)- Pt complains of pain 9/10 sharp neck shoulders back shooting down spine . -(10/7/15, 1:35 p.m.)- c/o neck and shoulder pain 8/10 -(10/8/15, 11:06 a.m.)- c/o neck and shoulder pain 8/10 -(10/9/15, 5:14 a.m.) - Resident asked for [MEDICATION NAME], for pain 9/10 neck and shoulder pain The nurse's notes 9/29/15 - 10/9/15 did not document any calls to the physician or nurse practitioner regarding the resident's high pain levels or the frequent administration of PRN medication for pain. Moreover, there was no reference in the notes regarding the 9/23/15 referral to the pain clinic. g. Physician Notes The record contained a physician progress notes [REDACTED]. A telephone order, dated 8/24/15, read, Increase to 10mg/325mg one to two every 4 hours as needed, Hold if sedated. The record did not contain a subsequent physician note. h. Interviews (1) Resident a) 10/6/15 On 10/6/15 at 3:30 p.m., the resident was asked about the presence of pain currently or recently that was not relieved. The resident responded, I'm always in pain .I think they need to give me something different .I just keep telling them about the neck brace from a month ago for ALS and it still hasn't arrived. I've asked the nurses and (restorative aide, certified nurse aide #10). b) 10/9/15 During a conversation with the resident on 10/9/15 at 1:45 p.m., the resident made the following comments: -I have pain all the time. It's bad. It's mostly up in my neck. It comes on hard and it makes me agitated. It's always at a 9 or 10. The medication calms it down but not for long. -I haven't seen the doctor in a long time. -I have pain at night but I try not to take my pain med. If I don't take it at 4 (am), I can't do anything during the day. They don't understand how much pain I'm in. I'm almost crying about it. I don't know why they haven't tried anything else like a patch. I was telling them and telling them and telling them. -PT (physical therapy) rubs my neck for 10 minutes. If I had more of it I think it'd be better. She has too many people. -A care conference would be good to know why I'm in pain. This is crazy. c) 10/13/15 On 10/13/15 at 1:00 p.m., the resident verbalized he received a soft cervical collar on Friday, 10/9/15 (ordered 8/24/15). The resident said, It helps hold my head up when I'm sitting. There's a little bit less pain (with it on). It's better than nothing. The resident further stated that the restorative aide provided him with ice packs several days a week for a couple hours - it helps. The resident added, I'd like a heating pad several times a day. It's ordered, but they're scared I'll get burned .When I don't have those meds I'm in tremendous pain. It gets so bad. That's why they got me on depression meds. (2) Staff a) Director of Nursing During interviews with the director of nursing (DON) on 10/9/15 at 1:15 p.m. and on 10/13/15 at 1:10 p.m., the DON reported that on 8/24/15, the dosage of [MEDICATION NAME] was increased for the resident because the nurse came to me and said he's complaining (the pain medication ordered at that time was) not effectively holding his pain. The DON acknowledged that the effectiveness of this increase had not been evaluated. The DON said, It's been overlooked. There's no weekly pain review .We need to establish his expected level of relief to see what his goal is. We want to see it below 5 .The previous social worker worked with some residents on palliative approaches. The IDT should explore trials of non-pharmacological interventions. b) Scheduler/Unit Assistant (UA) On 10/9/15 at 2:55 p.m., the UA was asked about the telephone order, dated 9/23/15, to refer pt to pain clinic. The UA verbalized she was responsible for scheduling appointments. The UA acknowledged a copy of this telephone order was placed on her desk, but she had not yet scheduled the appointment. The UA confirmed she did not ask another staff member to follow up on the order. c) Nurse (RN #3) On 10/13/15 at 10:25 a.m., a day-shift nurse (RN #3) verbalized she wrote the telephone order to refer the resident to the pain clinic on 9/23/15 for another nurse (LPN #2) who was concerned about the resident's ongoing pain. RN #3 indicated she was not aware that this order had not been followed up on. RN #3 said, Orders should be called in either that day or the next day at the latest. I gave it to (UA), made a copy, and gave it to (LPN #2). The nurse should follow up if (UA) couldn't do it. d) Nurse (LPN #2) On 10/13/15 at 10:40 a.m., LPN #2 reported the following: -The resident complains of neck and shoulder pain a lot. He's been taking (pain medication) every four hours. I've talked with his NP (nurse practitioner) several times, and she's not going to increase it. LPN #2 confirmed that her discussions with the NP about the resident's pain were not documented. -The NP ordered the referral to the pain clinic on 9/23/15. The LPN said, I asked (UA) last week about this order, and the UA said, I'm getting to it. -The first time she observed the resident wearing a collar was on Saturday, 10/10/15. Therapy is supposed to order the collar because it's supposed to be measured. -The nurse confirmed the 7/15/15 order for Therapy to place hot and cold packs as needed for muscle spasms was not carried out by either Therapy or Nursing. -The nurse did not know the reason [MEDICATION NAME] was being prescribed as a PRN medication, when it was given to the resident routinely on a daily basis. e) Director of Rehabilitation Services (DOR) On 10/13/15 at 11:00 a.m., the DOR, who started working in the facility in September, verbalized that Nursing asked Therapy to order the cervical collar in August. The DOR stated, I noticed it wasn't ordered when I came in, so I ordered it because (the resident) asked me about it .It's normally ordered by Nursing. Nursing can do the hot pack and cold pack. The DOR said the (7/15/15) order should have been written without stating that Therapy was to place the hot and cold packs The DOR further indicated that the involvement of residents and IDT members in quarterly care conference was important in identifying concerns such as ongoing pain and reviewing the effectiveness of interventions. The DOR said, We can ask, What is your pain level? The DOR confirmed the resident was not currently receiving therapy services. f) Restorative Aide On 10/13/15 at 11:10 a.m., the restorative aide (CNA #10) verbalized she gave the resident a shoulder massage for approximately 10 minutes, along with a heating pad, during his 30 minute session in the therapy room five to six mornings a week. CNA #10 stated, He tells me in the evening his shoulders are in pain. Some days he has more pain than others. He says, Tell them I need more pain medication, even after therapy. i. Facility Failures The facility failed to ensure resident #44 received the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being. The facility did not effectively address the resident's ongoing pain, as outlined below: -The resident's pain intensity and pain relief were not evaluated at regular intervals, per facility policy. -The care plans related to pain had not been updated since admission with revised interventions as the resident continued to report severe levels of pain. -The interdisciplinary team did not review the resident's pain management interventions to assess the effectiveness of ordered and planned interventions. -There was no evidence that the resident's pain was discussed at the only care conference conducted in after the resident's admission. There was no evidence the resident was involved in the development and ongoing processes of care planning. There were no Care Conference signature sheets. -The 7/15/15 order Therapy to place hot and cold packs as needed for muscle spasms was not carried out. -The 8/26/15 order Get soft cervical collar. Wear during the day was not implemented until 10/9/15 during the survey. -The anti-depressant [MEDICATION NAME] was added to the resident's medication regimen on 9/23/15. The resident indicated on 10/13/15 at 1:00 that [MEDICATION NAME] was initiated for him in part because of his depression related to experiencing persistent pain. -On 9/23/15, a telephone order Refer pt to pain clinic was written. This order was not carried out. -The resident's record did not contain evidence the physician was notified about a change in pain intensity, as indicated in the 10/6/15. 7:15 a.m. nurses' note: For the past several weeks it seems pt pain has changed in intensity pt says it is sharp stabbing often radiating from skull to spine pt says he does get some relief with meds . 2. Resident #3 (Cross reference F241; dignity) a. Record review Resident #3, [AGE] years old, admitted to the facility on [DATE] with the following diagnoses, according to the face sheet: diabetes mellitus type II, chronic pai[DIAGNOSES REDACTED], restless leg syndrome, overactive bladder, dyspnea, history of urinary tract infections (UTIs), and migraines. On 8/12/15 the admission minimum data set (MDS) documented the resident's brief interview for mental status (BIMS) score was 12 out of 15, which indicated that her cognitive status was moderately impaired. She required extensive assistance of one to two persons with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. The resident received scheduled and as needed (PRN) pain medications. She received non-medication interventions for pain. She had almost constant pain symptoms. She rated her pain level at eight out of ten with ten being the worst pain level. On 8/22/15 (last revised) the pain care plan documented that the resident had chronic pain related to her [DIAGNOSES REDACTED]. She received scheduled and PRN pain medication. The interventions included: - Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions 30 min (minutes) after administration. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Hospice consults as indicated. -Observe/document for probable cause of each pain episode. Remove/limit causes where possible. -Observe/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. -Provide non-pharmacological interventions: hot/cold pack application, positioning/support, assistive devices/braces, exercise program, stretching exercises, massage, recreational therapy, activity programming, music, behavior management, aromatherapy, chaplain/religious support if requested, counseling/support via psychology, social services. -Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to s/sx (signs and symptoms) or c/o (complaint of) pain or discomfort. Therapy referral as indicated. On 8/10/15 the pain evaluation form documented that the resident had chronic pain from a prior back surgery and arthritic shoulders. She experienced arthritic and [MEDICAL CONDITION] pain. She described it as a sharp ache. She rated her pain level at eight out of ten. The worst pain level was ten out of ten and the best level was six out of ten. The goal was to get her pain level to where it hurt a little bit/mild pain. She was not satisfied with current level of pain control and wanted an alternative to pain medications. Nothing else was documented regarding this request for alternative treatments. Rest, ice/cold pack, and medication therapy was effective for pain control. She reported that her pain was worst in the morning upon waking. She was able to verbalize pain. She reported that the pain interfered with sleep and physical activity. On 10/15 the medication administration records (MARs) and treatment administration records (TARs) documented the following orders, in pertinent part: - Order date: 8/5/15: [MEDICATION NAME] 1500 milligrams (mg) by mouth (p.o.) at bedtime for joint pain. - Order date: 8/5/15: [MEDICATION NAME] Chloride extended release (ER) 10 mg p.o. daily for bladder spasms. - Order date: 8/5/15: Requip 3 mg p.o. at bedtime for RLS. - Order date: 8/5/15: Tylenol extra strength (ES) 1,000 mg p.o. at bedtime for pain. - Order date: 8/5/15: [MEDICATION NAME] 300 mg p.o. twice a day for [MEDICAL CONDITION] pain. - Order date: 8/5/15: [MEDICATION NAME] 600 mg p.o. twice a day for [MEDICAL CONDITION] pain. - Order date: 8/5/15: Apply cold compress for comfort as needed (PRN) every four hours for [MEDICAL CONDITION]. - Order date: 8/5/15: [MEDICATION NAME] Migraine 250/250/65 mg give one tablet (tab) p.o. every six hrs PRN for migraines. - Order date: 8/5/15: [MEDICATION NAME] 5/325 mg give one tab p.o. every four hours PRN for pain. - Order date: 9/8/15: Tylenol 650 mg p.o. every four hours PRN for pain may take with [MEDICATION NAME]. - Order date: 8/6/15: Observe for pain every shift. If pain present, complete pain flow sheet and treat trying non-pharmacologic interventions prior to medicating, if appropriate. Document in the progress notes (PNs). b. Resident interview On 10/6/15 at 2:53 p.m. the resident reported that the interview might be interrupted by the Certified Nursing Aides (CNAs) because she had told them at 11:00 a.m. that she needed to use the bathroom. She was observed rubbing her legs. She reported that the longer she waited to be transferred to bed so she could use the bedpan, the more her legs would hurt her. She said she had to wait for a long time for the staff to assist her to the toilet. She reported that sometimes her legs would hurt so bad that she could not assist the staff with her bed mobility. She reported that she told the staff all the time how bad she hurt when they made her wait but they did not do anything about it. At 3:44 p.m. the staff had not yet responded to the resident's request to use the bathroom The resident turned on the call light at 3:44 p.m. so she could request to use the bathroom again. She repeated that she had been waiting for assistance since 11:00 a.m. and how bad she was hurting as she continued to rub her legs. She reported that her pain level currently was eight out of ten. She reported that most days she had no problem with her pain level but on the days like today when she had to wait a long time to be given assistance with her transfers, her pain level would jump to ten out of ten. She reported that her pain level was comfortable for her at five out of ten. She reported that it was difficult to get her pain level under control once she had reached that level of pain. She reported that when she experienced pain she would notify the CNAs and they would tell the nurse. She reported that most of the time when she told the CNAs about her pain the nurse would not give her anything, so she would have to hunt down the nurse to give her the pain medications. She did not think the CNAs were good at telling the nurse that she was in pain. c. Observations (1) 10/6/15 On 10/6/15 at 3:54 p.m. CNA #16 responded to the resident's call light. The resident told the CNA she had needed to go to the bathroom since 11:00 a.m. and she was hurting. The CNA did not respond to the resident ' s statement. At 3:59 p.m. CNA#16 went to find CNA #13 to assist with the cares and transfer. At 4:01 p.m. CNA #16 returned to the room with the Hoyer lift. At 4:04 p.m. the resident asked CNA #16 to go and find the other CNA. CNA #16 left the room. At 4:06 p.m. both CNAs returned to the resident's room. They began transferring the resident to her bed using the Hoyer lift. At 4:07 p.m. the resident was not able to hold herself up on the bed during the insertion of the bedpan. She reported it was because she had stayed up in the wheelchair for too long and was weak and in pain. The CNAs continued cares with the resident without responding to the resident's statements about pain and weakness. At 4:17 p.m. to 4:23 p.m. the CNAs stood in the hallway waiting for the resident to use the bedpan in private. At 4:36 p.m. the CNAs transferred the resident from the bed to the wheelchair using the Hoyer lift. The resident reported that her pain level was at seven out of ten. She said she would ask the nurse on the way to the activity for a pain pill. The CNAs were not observed to notify the nurse of the resident's pain level. (2) 10/7/15 On 10/7/15 at 2:27 p.m. the resident was observed asking CNA #4 for assistance to the bathroom. The CNA told the resident that the next shift was coming on in three minutes to four minutes so they could help her. The CNA reported that she would notify the next shift so they could assist her first. The resident stated to the CNA, This is what I mean. You guys always tell me the next shift will do it and I'm hurting. This is what makes me mad. They don't get it (that) my legs hurt a lot when I have to wait a long time for someone to help me. The CNA did not respond. She did not offer to notify the nurse that the resident had reported she was hurting. At 2:42 p.m. CNA #16 stopped by and spoke to the resident. The resident told her that she had been waiting since the prior shift to go to the bathroom and her legs were hurting. The CNA reported that she would try to get her to the toilet soon. At 2:56 p.m. the resident put her call light on and stated, I don't know if the CNAs understand that I have to go to the bathroom and my legs are killing me? She reported that her pain level was eight out of ten. She said when she saw the CNAs; she would make sure they told the nurse about her pain. At 2:58 p.m. Licensed Practical Nurse (LPN) #5 answered the resident's

Based on resident and staff interview, observations, and record review, the facility failed to promote care for five (#3, #28, #88, #132, and #56) of six out of 47 total residents sampled in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality. Staff failed to respond to resident requests in a respectful manner, enter resident rooms in a respectful manner or ensured resident permission, as well as privacy, with cares. Resident #3 sat in urine for five hours which, in addition to incontinence, frustrated, angered and embarrassed her and made her feel less important than other residents. The findings include: I. Facility's policies and procedures (P&P) On 10/9/15 at 10:48 a.m. a copy of the Resident Dignity & Personal Privacy P&P was received from the Director of Nursing (DON). The Resident Dignity & Personal Privacy P&P (revision date 6/07) documented the following, in pertinent part: The facility provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy. Each resident's right to personal privacy includes the confidentiality of his or her personal and clinical affairs. Dignity means that when interacting with residents, staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth .Knock on doors before entering, announce your presence .Groom appropriately and to resident's desire .Drape and dress residents appropriately at all times to avoid exposure and embarrassment . II. Resident #3 A. Resident Status Resident #3, [AGE] years old, was admitted to the facility on [DATE] with the following diagnoses, according to the face sheet: diabetes mellitus type II, chronic pai[DIAGNOSES REDACTED], restless leg syndrome, overactive bladder, dyspnea, history of urinary tract infections (UTIs), and migraines. The 8/12/15 admission minimum data set (MDS) documented the resident's brief interview for mental status (BIMS) score was 12 out of 15, which indicated that her cognitive status was moderately impaired. She required extensive assistance of one to two persons with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. She was not on a special toileting program. She was frequently incontinent of bladder and always continent of bowel. On 8/22/15 (last updated) the incontinence care plan documented that the resident had occasional incontinence. The interventions included, Activities: notify nursing if incontinent during activities. Clean peri-area with each incontinence episode. Encourage fluids during the day to promote prompted voiding responses. Ensure the resident has unobstructed path to the bathroom. Establish voiding patterns. Staff to offer prompted toileting upon arising, before and after meals, at bed time, and as requested per resident. Hand washing before and after delivery of care. Have call light within easy reach. Observe/document/report PRN (as needed) any possible causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke, and medication side effects. The care plan did not include the resident was wearing incontinence briefs. On 8/6/15 the bowel and bladder assessment documented that the resident was cognitively intact. She was able to be understood and understand others. She was incontinent at times with bladder. She would leak urine with physical stress. She occasionally had urgency. She was not able to determine how long she could hold her urine stream. She was not able to determine if she could empty her bladder. She was not able to determine if she had the urge to go to the bathroom but was able to feel urine passing. She was able to determine if she was wet. The possible contributing factor included her history of UTIs. She was independent with accessing food and fluids. The resident did not want to participate in the bowel and bladder program and the risks/benefits had been discussed with her. The overall plan was to continue to monitor her bowel and bladder status. The undated Kardex documented that the resident was continent of bowel and frequently incontinent of bladder. No toileting considerations were documented. The directive to staff on the care plan, to offer prompted toileting upon arising, before and after meals, at bed time, and as requested per resident, was not referenced. B. Resident interview On 10/6/15 at 2:53 p.m. the resident reported the interview might be interrupted by the Certified Nursing Aides (CNAs) because she had told them at 11:00 a.m. that she needed to use the bathroom. She said the CNAs tell her she has to wait until the next shift before she can get assistance with toileting. She reported it made her mad and frustrated when she needed to go to the bathroom. She said the staff told her she had to wait until other residents who needed more assistance were taken care of before they could help her. She stated this made her feel like she was not important, that the staff did not care that she had to sit in her urine. She said the long waits led to incontinent episodes. She said, Who wants to sit in their own pee and poop. It's disgusting. Why won't they help me so I don't have to run around smelling like this? She said she felt dirty all the time. She then stated she had to go to the bathroom and propelled her electric wheelchair down the hallway to find staff but before she left she repeated she that she had asked the CNAs to assist her to the bathroom around 11:00 a.m. but they had not responded yet and said staff would make her wait until the next shift. At 3:44 p.m. the resident was interviewed again and said the staff had not responded to her request to use the bathroom. She turned on the call light at 3:44 p.m. so she, again, could request to use the bathroom. She repeated that she had been waiting for assistance since 11:00 a.m. when she first requested to use the bathroom. C. Observations 1. 10/6/15 On 10/6/15 at 3:45 p.m. Registered Nurse (RN) #1 responded to the resident's call light and asked the resident what she needed. The resident told her that she had asked the staff at 11:00 a.m. to assist her in using the bathroom but no one had come to help her. The RN was overheard saying to the resident that she would keep the call light turned on so she could time the CNAs' response times to the call light. The resident agreed and stated, Watch they will come answer it, but tell me I have to wait until the next shift. The RN found two CNAs in the hallway and asked them to provide assistance to the resident. At 3:54 p.m. CNA #16 responded to the call light. The resident told her that she had needed to go to the bathroom since 11:00 a.m. The CNA did not respond to the resident's statement. The CNA closed the door. The CNA asked if her partner, CNA #13, was aware that the resident needed to use the bedpan. The resident said, I hope, since I told her at 11:00 a.m. At 3:59 p.m. CNA#16 went to find CNA #13 to assist with the resident's cares and transfer. At 4:01 p.m. CNA #16 returned to the room with the Hoyer lift. At 4:04 p.m. the resident asked CNA #16 to go and find the other CNA. CNA #16 left the room. At 4:06 p.m. both CNAs returned to the resident's room. They began transferring the resident to her bed using the Hoyer lift. At 4:07 p.m. the resident's incontinence brief was observed; it was soaked with strong malodorous smelling urine and some liquid stool. At 4:17 p.m. to 4:23 p.m. staff stood in the hallway waiting for the resident to use the bedpan in private. At 4:36 p.m. the CNAs transferred the resident from the bed to the wheelchair using the Hoyer lift. The resident then continued on to an activity. On 10/6/15 at 4:31 p.m. CNA #13 reported that she had worked with the resident for the past month and CNA #16 had worked with the resident since the resident's admission. 2. 10/7/15 On 10/7/15 at 2:27 p.m. the resident was observed asking CNA #4 to assist in taking her to the bathroom. The CNA told the resident the next shift was coming on in three minutes to four minutes so they could help her. The CNA reported that she would notify the next shift so they could assist her first. The resident stated, This is what I mean. They always tell me the next shift will do it. At 2:29 p.m. CNA #4 brought the Hoyer lift and parked it in the resident's room. She closed the resident's door while the resident remained in hallway. She eventually left the room and walked down the hallway. At 2:41 p.m. the next shift of CNAs had arrived and were doing report and rounds with each other. No one stopped to tell the resident if they were aware of her need to use the toilet. At 2:42 p.m. CNA #16 stopped by and spoke to the resident. The CNA asked the resident if she would be able to wait for assistance to the bathroom until 4:00 p.m. The CNA told the resident that she was sorry for the delay, but she was assigned to do one on one sitting with another resident and could not leave her. The CNA then ran after the resident for whom she was providing one to one sitting. The resident stated, What did I tell you? They always tell me to wait for the next shift or wait many more hours than what I've already waited. She said, This is what they (CNAs) do all the time. This tells me that my needs aren't as important as the other residents' needs. This isn't fair that I have to sit in my urine for all this time. The resident said this happens to her all the time. She reported it made her embarrassed that she has to sit in her urine and feces for long periods of time. She said she used to get really angry about it but now she knew it would not do her any good, so she had resolved herself to the fact that the CNAs would not help her go to the toilet unless the other residents' needs had been taken care of before hers. At 2:56 p.m. she put her call light on and stated, I don't know if the CNAs understand that I have to go to the bathroom? At 2:58 p.m. Licensed Practical Nurse (LPN) #5 answered the call light but did not turn the call light off and did not offer to take the resident to the toilet. The LPN said she would let the staff know that the resident needed to use the toilet. The resident told her that the CNAs had told her she had to wait until 4:00 p.m. before they could help her. The LPN reported that she would tell the CNAs to help her now. At 3:04 p.m. CNA #16 and CNA #8 arrived at the resident's room. CNA #16 said she had to borrow CNA #8 from another unit because her partner was busy with other residents. At 3:11 p.m. the resident reported that she was incontinent a lot and usually soaked her pants because of how long she waited for assistance. The resident stated she had wet herself while waiting for the staff to help her. The CNAs got the resident transferred to bed from the wheelchair. The incontinence brief was saturated with urine but not malodorous. At 3:20 p.m. and until 3:28 p.m. the resident used the bedpan in private. CNA #8 reported that she was not familiar with the resident's routine because this was not her usual hall to work. At 3:31 p.m. CNA #8 provided peri-care. The resident's skin was intact but red. At 3:34 p.m. both CNAs agreed that the Hoyer sling was too large for the resident. CNA #16 asked the resident if she could use the over sized sling on her for this transfer. The resident stated she had slid out of the over sized sling once before and did not want to use the sling. The CNA tried tucking it under the resident but the resident became agitated and said, No! I told you I slipped out of the blue one. I don't want another fall. At 3:40 p.m. CNA #8 reported that she would have to go find another sling and would return shortly. At 3:41 p.m. CNA #8 returned with the correct sized sling. The CNAs transferred the resident from the bed to the wheelchair. D. Staff Interviews On 10/7/15 at 4:24 p.m. CNA #16 said she had worked at the facility for the past ten years. She reported she had worked with this resident since the resident's admission. She said her normal assignment was on hallway three where resident #3 resided. -She said there was plenty of staff and she sometimes had to wait for assistance from other staff members because it took two persons to transfer the resident. She reported the CNA workload on hallway three was heavy during certain times of the day, like at shift change, so residents needed to wait for assistance because they were not able to assist everyone at once. She said she did not have to borrow staff from another unit often. -She stated resident #3 would wait until change of shift before asking for assistance so it made it hard for the staff to help her in a timely manner. She reported they usually worked with the resident to determine the time she wanted assistance to the bathroom. She said she did not feel the resident had to wait a long time for assistance but could not speak about what occurred on the day shift. She stated the resident had complained to her frequently in the past that day shift would refuse to help her to the bathroom and would tell her to wait for the next shift. She said she had not reported this information to the nurse or to management. -She stated that a resident's continence status was documented in the computer system. She said CNAs were responsible for charting every time they took someone to the bathroom. -She said the resident was a mix of continent and incontinent and the resident was not able to make it to the bedpan all the time. She stated staff took the resident to the bathroom at least three times on her shift (evening shift). She further stated she felt the resident waits until the evening shift to use the bedpan because evening shift staff was most willing to transfer her frequently. On 10/13/15 at 8:18 a.m. the Director of Nursing (DON) reported she would expect her staff to check on the resident for toileting needs every two hours and on an as needed basis like for all residents. She said she would expect the CNAs to assist the resident with toileting needs upon her request and not make her wait. On 10/13/15 at 11:26 a.m. CNA #17, who worked the day shift, reported she had worked at the facility for eight years and hallway three has been her assignment. -She said she works with the resident on establishing a time to take her to the toilet because it requires two staff to transfer the resident. She said they are not always able to take her to the toilet when she requests it because two CNAs have to be available at the same time. She stated she responds quickly to the resident's call light and request for toileting, but explains to her that she has to wait until she could get the Hoyer lift and the other CNA. She said she felt the resident understood this. -She reported the resident is transferred to the toilet on average twice her shift. She reported that sometimes it is less than twice a shift because the resident would not request to be toileted. The resident was not a toileting program and was not being monitored every two hours since she was independent and able to communicate if she needed assistance with toileting. On 10/13/15 at 11:16 a.m. LPN #5, who worked the day shift on hallway three, said the CNAs were attentive to resident #3's requests to be toileted. -She stated the CNAs work out a time with the resident since she requires two staff for transfers. She reported she was not aware the resident was waiting five hours or longer between continence checks. -She said the resident was independent and would be able to communicate the need to toilet so she would not expect the staff to have her on a special schedule to ensure she was toileted. She reported she would have to educate the resident to not wait such a long time between toileting. She was not aware the staff was asking her to wait the long periods of time for staff assistance. On 10/13/15 at 11:44 a.m. CNA #4, who worked the day shift on hallway three, reported the resident usually asked for assistance during change of shift or during the meal. She said if they had more staff, they might be able to accommodate her needs more timely. She stated it was difficult to take the resident to the toilet during busy times of day because the resident's transfer required two persons and a lift. -She said the CNAs usually worked with the resident to set up a time for toileting. She reported that the resident was not a toileting program and the resident did not require special treatment with toileting because she could report her needs to the staff. -She stated the resident was taken to the toilet on average once a shift. She confirmed she had asked the resident to wait for the oncoming shift when she had a few minutes left to her shift. She said overtime work was not accepted by management. III. Resident #28 A. Resident Status Resident #28, age 63, admitted into the facility 1/7/11 and again on 11/8/12 with [DIAGNOSES REDACTED]. The 8/8/15 MDS assessment revealed the brief interview for mental status (BIMS) score of 15 which indicated the resident's cognition was intact. Section J (Health Conditions) showed resident received scheduled pain medication and received as needed pain medication. During the review period, the resident reported pain was almost constant; made it hard to sleep at night, limited his day to day activities and the resident reported work pain level was a ten on a scale of zero to ten. The resident had a life expectancy of six months or less. B. Observation On 10/6/15 at approximately 4:40 p.m., the resident reported he still needed his 4:00 p.m. pain medication. The resident wanted to remind the nurse of his scheduled medication and propelled himself from the milieu area towards the 200 hallway where he resided. The resident approached LPN #6 who was scheduled to work on a hallway other than 200. The resident was positioned directly in front of the LPN when he called out the LPN's name. The LPN in the milieu looked directly at the resident then looked around other hallways. The LPN did not acknowledge the resident as he called out the LPN's name four times within two feet from the LPN. The LPN did not acknowledge the resident, did not request the resident to hold on, but rather ignored the resident's attempt to gain his attention. C. Interviews On 10/6/15 at 4:47 p.m., the resident stated LPN #6 ignores him when he tries to ask the LPN a question. The resident said it was common for him to approach staff and feel ignored. Alternatively, they often tell him they are busy with something else. On 10/9/15 at 11:29 a.m., the resident was interviewed again. He stated he did not feel the facility provided him the care he deserved. He stated staff routinely told him to wait a minute as they helped others. He felt if he waited every time he was told to hold on by staff, things he needed to get done wouldn't be addressed. On 10/13/15 at 11:20 a.m., the director of nursing (DON) was interviewed. The DON stated staff should acknowledge residents when approached and help from staff was needed. She said residents should not feel ignored in their home and should be treated respectfully and in a dignified manner. The DON stated the LPN should have acknowledged the resident to show the resident's needs mattered to the LPN. IV. Resident #88 A. Resident Status Resident 88, age 82, admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The 9/19/15 MDS assessment showed a BIMS of eight out of 15. The resident's score indicated her cognition was moderately impaired. Section F (Functional Status) showed the resident was independent with transfers, locomotion on/off unit, and no impairment or limitation in range of motion of upper and lower extremities. Section E (Behaviors) reported the resident did not exhibit wandering behaviors. B. Interviews On 10/7/15 at 8:49 a.m., the resident said staff enter her room without knocking. She felt she was not treated in a dignified and respectful manner. The resident felt when staff came in to help her roommate, staff did not acknowledge her presence, did not greet her or offer her any assistance when they were in her room. The resident felt she deserved a better service and staff should see how she was doing. C. Observation On 10/7/15 at 9:15 a.m. the activity manager (AM) walked into the resident's room without knocking or announcing her presence. The AM had mail in her hands as she entered the resident's room. The AM said she walked into the room without knocking because she did not know anyone was in the room. She said she was in the room to deliver mail, then placed a few pieces onto the roommate's bed and exited the room. The resident said it was the first time the AM had spoken to her and it wasn't common for the AM or other resident's to say anything before they entered her room. Subsequently, on 10/9/15 at 11:12 a.m. and 11:14 a.m., LPN #6 entered room [ROOM NUMBER] without knocking each time the LPN entered the room to administer medication. D. Staff Interview On 10/9/15 at 12:18 p.m., the social services director was interviewed. The SSD said she expected staff to knock before they entered a resident's room. She stated the facility was the resident's home and that staff, in failing to knock, were not treating residents in a dignified manner. On 10/13/15 at 11:20 a.m., the DON said she expected staff to knock on resident doors before they enter a room. She stated staff's failure to knock on doors or acknowledge the resident after entering was a dignity issue. The DON said residents deserved to be treated in a respectful and dignified manner. V. Resident #132 A. Resident Status Resident #132, age [AGE] years, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A comprehensive assessment had not been completed for the resident as the resident was newly admitted to the facility. The resident transferred to another facility on 10/7/15. B. Observation On 10/7/15 at 9:39 a.m., registered nurse (RN) #3 entered the resident's room without knocking and requesting permission to enter. The RN announced to the resident that she was going to change the resident's catheter. Without pulling the privacy curtain, the RN pulled down the covers and pulled up the resident's hospital gown, exposing the resident's incontinence brief. The resident stated she was embarrassed the nurse had to do this. The RN commented she was accustomed to this because it was part of her job. C. Staff Interview On 10/13/15 at 5:18 p.m., an interview with the nursing home administrator (NHA) in the presence of consultant (conslt) #2 revealed that it was his expectation that staff knock and await permission to enter a resident's room. The NHA stated that it was not acceptable for the nurse to begin providing intimate cares to a resident without first providing for privacy and obtaining resident consent for the procedure. The NHA acknowledged the interaction between resident #132 and RN #3 did not meet his expectations. VI. Resident #56 A. Resident Status Resident #56, age [AGE] years, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The 8/13/15 admission minimum data set (MDS) assessment revealed: -The resident had short and long term memory impairment and was severely impaired with decision making. -The resident could not recall current season, location of room, staff names/faces, or that she was in a nursing home. -The resident exhibited signs and symptoms of [MEDICAL CONDITION] that included inattention and disorganized thinking. - The resident did not exhibit [MEDICAL CONDITION]. -The resident had other behavior symptoms not directed towards others on one to three days of the observation period. -The resident did not exhibit rejection of care during the observation period. -The resident required extensive assistance from two staff for bed mobility, transfers, locomotion on and off the unit, dressing toileting, and personal hygiene. -The resident was frequently incontinent of bladder and always continent of bowel. -The resident had a [DIAGNOSES REDACTED]. The 8/22/15 incontinence care plan stated that the resident was incontinent related to confusion and dementia. The goal was that the resident would not develop impaired skin integrity r/t (related to) incontinence through the next review date. The approaches included: -Activities: notify nursing if incontinent during activities. -Clean peri-area with each incontinence episode. -Prompt toileting upon arising, before and after meals, at bed time, and prn. B. Observations On 10/8/15 at 11:01 a.m., the resident was observed to be awake and wheeling in her chair in the library. There were wet spots on the front shins of her pants from weeping [MEDICAL CONDITION]. A dried wet spot was present on the right side of the resident's lap. On 10/8/15 at 11:23 a.m., the resident was escorted to her room by LPN #6 and registered nurse (RN) #4 for observation of the resident's shins and wound care. The RN, who was working the floor as an aide, was initially present to assist the LPN with any cares, but then left to contact hospice about the resident's weeping [MEDICAL CONDITION]. After completing observation of the resident's shins and wound care to the left stasis ulcer, the LPN left the resident in the pants with the wet shins and the dried wet spot on the right lap. The LPN escorted the resident to dining room to wait for lunch. On 10/8/15 at 12:55 p.m., the resident was escorted to her room by CNA #9. CNA #9 acknowledged the dried wet spot on the resident's right lap area. The CNA stated she did not know what caused the wet spot to the lap. The wet spots on the shins were smaller and drying after the wound care. CNA #14 arrived to assist with transfer and cares. Each CNA denied providing perineal/toileting care to the resident that shift. The CNAs were unable to state when the resident was gotten up from bed because, they reported, the hospice CNA was provided the morning cares to the resident that morning. The CNAs acknowledged they were each responsible for a whole hall of residents that morning. Examination of the resident's pants and brief after cares revealed the pants had dried wetness inside and outside of the lap area. The brief was wet with urine. The CNA stated the resident is supposed to be changed every two hours but that this was not always possible when they were not fully staffed. C. Staff Interviews On 10/8/15 at 4:48 p.m., an interview with the DON revealed that it was her expectation that residents received toileting as needed and that residents were kept clean and dry. The DON stated that LPN #6 should have assisted the resident to change or should have obtained a CNA to assist the resident to change her pants and brief after wound care on 10/8/15. The DON stated the dried wet spot on the resident's lap could have been from urine leaking from the resident's brief and a change of brief should have been completed prior to lunch. The DON stated she felt it was a dignity issue to send the resident to lunch in pants with wet shins and a dried wet spot on the lap.

Based on observations, interviews, and record review, the facility failed to ensure that one of three residents with pressure ulcers (#26) out of 47 total residents sampled, received the care and services necessary to ensure healing of an existing pressure sore and the treatment and services necessary to promote healing, prevent infection, and prevent new sores from developing. Resident #26 entered the facility with multiple risk factors for pressure ulcer development, including [MEDICAL CONDITION] (MS) with functional limitations, incontinence of stool, and the presence of a Stage IV pressure ulcer on his left buttock. Staff failed to comprehensively assess, monitor and document information on the status of resident's skin in order to evaluate the effectiveness of treatments. Staff also failed to communicate with the interdisciplinary team (IDT) including therapists and medical providers, regarding measures to relieve pressure, and failed to re-evaluate planned interventions when the resident's existing ulcer failed to heal and he developed three new ulcers. The facility's failures contributed to the formation of pressure areas on the resident's right buttock and heels and to the failure of the wounds, both existing and acquired, to heal. The finding included: I. Resident Status Resident #26, age less than [AGE] years, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The 7/31/15 significant change minimum data set (MDS) assessment revealed: -The resident was cognitively intact as evidenced by a brief interview for mental status score of 15/15. -The resident did not have behaviors that impacted self or others and did not exhibit rejection of care during the MDS observation period. -The resident required extensive assistance from two staff for bed mobility, transfers, toilet use, and personal hygiene. -The resident hand limitations to functional range of motion for one upper extremity and for both lower extremities. -The resident had an indwelling Foley catheter and was frequently incontinent of stool. -The resident had a stage one or greater pressure ulcer; was at-risk of developing additional ulcers, and an unhealed stage III which was not present on admission/re-admission, an unhealed stage IV pressure ulcer that was present on admission/re-admission; and one unstageable/deep tissue injury. -The dimension of the stage IV in centimeters was 3.0 length (L) x 4.2 width (W) x 2.8 depth (D) -The stage III and stage IV ulcers were present on the previous assessment. -The resident had a pressure relieving device to his bed, his chair, received pressure ulcer care, and dressings to the feet. -The resident was 68 inches tall and 228 pounds and had not lost or gained weight in the last six months. The 8/11/15 pressure ulcer care plan for the resident stated the resident had a stage IV pressure ulcer to his buttock related to disease process of [MEDICAL CONDITION], being wheelchair bound, impaired mobility, and incontinence. The resident care plan stated the resident also has a stage 3 to hip area. The care plan stated the stage IV ulcer had had infection with osteo[DIAGNOSES REDACTED] (bone infection). The goal was for the resident to have the infection treated and healed with intravenous antibiotic therapy and current wound treatment. The approaches were: -Administer medications as ordered. Observe/document for side effects and effectiveness. -Administer treatments as ordered and observe for effectiveness -Complete a full body check weekly and document -Encourage resident to Reposition in chair frequently for comfort and pressure reduction -Follow facility policies/protocols for the prevention/treatment of [REDACTED]. -IDT (interdisciplinary team) referrals as indicated, i.e., RD (registered dietitian), PT, OT (physical and occupational therapy) -Observe nutritional status. Serve diet as ordered, observe intake and record. -Obtain and observe lab/diagnostic work as ordered. Report results to MD (medical doctor) and follow up as indicated. -Provide incontinence care after each incontinence episode, or per established toileting plan -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudates. The care plan did not address and was not updated to reflect the presence of the pressure areas to the resident's bilateral heels and right buttock. (See record review below) II. Resident Interview On 10/13/15 at 10:53 a.m., an interview with the resident revealed: -The resident stated he arrived at the facility with one pressure ulcer to his left buttock. According to the resident, the left ulcer developed when he was at home and resulted in his admission to the hospital and then another facility prior to admitting to the current facility. -The resident stated he did not want to get anyone in trouble, but his wound to the right buttock and both of his heels developed while he was a resident at the facility. -The resident stated that since arriving at the facility, he had been on the same air mattress and in the same wheelchair with the same wheelchair cushion. The resident stated he got up in his wheelchair and was in his wheelchair whenever he was out of bed in the afternoon. -The resident stated he had not been approached by the IDT since admission and he had not been screened for devices to prevent further skin breakdown to his heels or buttocks while in bed or up in his wheelchair. III. Observations On 10/6/15 at 4:02 p.m., the resident was observed in his wheelchair. The wheelchair was both too high as evidenced by his feet not touching the floor and too wide to fit the resident comfortably. The resident was slumped to his right with his head on his right hand. The resident stated that the wheelchair was too big. On 10/9/15 at 1:45 p.m., the resident was observed in his room. The resident was in his wheelchair. The chair was three to four inches too wide for the resident at the side. The resident's feet did not touch the floor. A black one to two inch thick cushion was in place in the seat of the wheelchair. On 10/9/15 at 3:56 p.m., licensed practical nurse (LPN) #4 and registered nurse (RN) #5 were observed while providing care to the resident's pressure wounds. Observation revealed: -The dressing was removed from the right buttock pressure ulcer (acquired after admission). The wound base had thick, yellowish/brown eschar and red meaty tissue to the wound walls. The top of the wound had black eschar. The wound appeared deep but without tunneling. -The left buttock pressure ulcer (present on admission) had a red meaty center and was small in diameter. The peri-wound skin was sheared from the drape and was red and weeping serous (clear) fluid. His skin had scabs from the drape on his skin. -The wounds were each cleaned, dressed and [DEVICE] applied following physician orders [REDACTED]. -During the change to the right buttock wound, the RN stated to the LPN that she noticed last time she changed the dressing that the tissue had adhered to the dressing and had torn the new tissue. The RN reported that the resident has skin that is sensitive to tape. -The RN stated that one challenge for healing the resident's wound was that the resident could have five bowel movements a day. The bowel movements often contaminated the wound vac and necessitated additional changes to the wound vac. No measurements were obtained during the wound care. Wound care to the heels was not offered at this time and heel wounds were not observed. III. Record Review Review of admission documents, Skin-Weekly Pressure Ulcer Records, Head-to-Toe Skin Checks, Daily Skilled Nursing Notes, and Nurse's Notes revealed the resident acquired three additional pressure ulcers after admission. These pressure ulcers, as well as an existing pressure ulcer on admission, did not heal. Record review revealed the ulcers were inadequately documented to monitor progress and the effectiveness of treatments. Care plan interventions (see above) were not implemented or revised when new ulcers developed. A. Admission Documents -The 4/29/15 history and physical from the resident's previous facility revealed that the resident had, a decubitus (pressure) ulcer on his left buttock with vacuum in place. -The 5/18/15 at 9:41 p.m., and 2:35 p.m., nursing notes from the previous facility stated the resident had a [DEVICE] (vac) in place on his left buttock. -Other notes from the previous facility in the admission documentation showed the presence of a stage IV pressure wound to the resident's left buttock/coccyx area and that the wound had been infected on admission to the hospital in April 2015. B. Skin/Wound Documentation 1. Skin-Weekly Pressure Ulcer Record -The 6/16/15 record, which was the first such record available in the resident chart since his admission 5/19/15 with a Stage IV pressure ulcer, showed the resident had an existing pressure ulcer on the left buttock. The wound was listed as a stage III that measured 5.5 x 4x4. The wound was 100% granulation tissue. No drainage, odor, or undermining/tunneling was present. The wound edges and surrounding skin were normal. The wound was unchanged. -The 7/8/15 record, which was the next such record available, showed the resident had an existing pressure area on the rear left iliac crest (area above the left buttock) that was present at admission. The wound was a stage IV and measured 4x3x3.2. There was undermining of 1.5 cm at one o'clock. The wound bed was red. There was no drainage or odor. The wound edges were pink and the surrounding skin was normal. The wound was improved, even though undermining was observed which indicated the base of the wound was larger than observed. (See: Kimmel, H and M Pressure Ulcers, http://wound.med.nyu.edu/what-we-treat/pressure-ulcers.) The note stated the resident wound doing well. Treatment changed to effected peri wound area skin. The change was described as, Moist to dry dressing daily and PRN (as needed) apply antifungal cream to peri wound skin [MEDICATION NAME] 100 mg po (by mouth) bid (twice daily) x 10 days. -The 7/15/15 record for the left trochanter (hip) stated the wound was existing and present on admission. The wound was a stage IV pressure ulcer that measured 4.5x2.5x4. The wound bed was normal for the resident's skin. There was a moderate amount of serous (clear body fluid) drainage. No odor was present. The wound edges and surrounding skin were marked as normal for skin. The wound was listed as improved even though it had developed drainage and had an increase in length and depth. The plan was to change treatments and a note stated to see physician orders. -The 7/15/15 record for the right buttock stated the resident acquired a new pressure area in the facility which was first identified on 7/15/15. (But see below for wound identification on 7/13/15) The wound was an unstageable pressure ulcer that measured 4x2.5x0. The wound was in the right gluteal fold area. The wound bed was black. There was moderate serosanguinous (bloody and clear body fluid) drainage present. No odor was detected. The area was debrided to 100% granulation tissue. The wound edges and surrounding skin were marked normal for skin. The plan was to continue to follow (the wound) weekly. The treatment was to be triple antibiotic ointment (TAO) mixed with Santyl covered with a foam dressing that was changed daily. -The 7/15/15 record for the lower extremity stated the resident developed a new pressure area acquired at the facility that was on the left lateral calf per page two of the form but noted on the right lower leg (rear) per page three of the form. The wound was discovered on wound rounds. The wound measured 1x1.5x0 and was unstageable. There was moderate serous drainage from the wound. The wound edges and the wound bed were normal for skin. The plan was to treat the area with a mix of TAO and Santyl, cover with foam and change daily. No additional documentation on this wound was found in the clinical record. The clinical record did not contain any additional documentation on the weekly pressure ulcer form for any of the wounds described above in the 7/13/15 MDS and during observation on 10/9/15 or in the Head-to-Toe Skin Checks and Nurse's Notes below. 2. Head-to-Toe Skin Checks -The 7/13/15 skin check stated that the resident had a new pressure area to the right gluteal fold. The wound was red, purple in color with open area noted. No measurements of the wound were present. No description of the wound bed, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. -The 7/24/15 skin check stated that the resident had existing pressure areas to the left and right buttock. The left buttock wound was 5x3xdeep and a little odor was noticed. The wound to the right gluteal fold was listed as 6mm long. The patient was noted to have an order for [REDACTED]. -The 7/25/15 skin check stated that the resident had existing pressure areas to the right gluteal fold and the left buttock. The wound vac was in place and working for the left buttock wound. The right gluteal fold pressure area was described as an open area. No description of the wound bed, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. -The 8/1/15 skin check stated the resident had existing pressure areas to the left trochanter and the right gluteal fold. No measurements or staging were recorded for either wound. No description of the wound bed, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. The form showed there was a small pressure ulcer to the right gluteal fold and that the wound vac was in place on the left buttock. -The 8/8/15 skin check stated the resident had existing pressure ulcers to the left buttock and right gluteal fold. No measurements or staging were recorded for either wound. No description of the wound bed, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. The form stated Right gluteal folds with large size of wound (sic). Cont(inue) tx (treatment) as ordered. The wound vac was documented to be intact on the left buttock. No description of the wound beds, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. This form did not provide information about the left heel pressure wound that was noted on the 8/5 daily skilled nurse's note (See below) -The 8/15/15 skin check stated the resident had existing pressure and non-pressure areas. The box for new pressure area was not marked, although a new pressure area to the left heel was identified on the form. The form showed the resident had a pressure wound to the left gluteal fold. No further information on the left buttock/gluteal fold wound was documented. The right gluteal fold measured 5x2.5 (no depth was listed) and was stage II. A new pressure area to the left heel measuring 3x2 was listed as a stage I. No description of the wound beds, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. This form did not provide information about the right pressure wound to the resident's heel noted on the daily skilled nurses notes on 8/9 for the right heel. (See below) -The 8/22/15 skin check stated the resident had existing pressure ulcers. The resident had open areas to the left and right gluteal folds that had dressing described as clean, dry and intact. The resident was noted to have a blister on the left heel. No description was provided of the right heel. No measurements or staging were recorded for any wound. No description of the wound beds, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. -The 8/25/15 skin check stated the resident had existing open areas. The wound on the left gluteal fold and right gluteal fold were noted to have dressings that were clean, dry and intact. The form stated the resident had a pressure area to the bilateral heels. The right heel was described as a dark/discoloration. No description was provided of the left heel. No measurements or staging were recorded for any wound. No description of the wound beds, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. -The 8/29/15 skin check stated the resident had existing pressure ulcers. The form showed the resident had wounds to the left and right gluteal folds and the left heel. There was no documentation on the pressure area to the right heel noted on the previous form. No measurements or staging were recorded for any wound. No description of the wound beds, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. The form did not reference the right heel blister that was noted on the 8/27 daily skilled nurse's note. (See below) -The 9/5/15 skin check stated the resident had existing pressure ulcers. The form showed the resident's left gluteal fold wound was pink and the wound was deep. The right gluteal fold wound had slough/ large brown discoloration. The form also showed black discoloration to the right heel and that a problem existed on the left heel. No measurements or staging were recorded for any wound. No description of the wound beds, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. -The 9/12/15 skin check showed the resident had existing pressure areas. The location, measurement, staging of the wounds was not documented. No description of the wound beds, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. The form stated dressings to the buttocks and left heel were changed. -The 9/17/15 skin check showed the resident had existing pressure areas to the left and right gluteal folds and both heels. The left gluteal ulcer measured 2.0x2.0x5.2. The right gluteal fold measured 7.0x6.5x3.0. The left heel measured 1.7x1.8x0.2. No staging was listed for the left heel. The right heel was listed as unstageable and measured as 2.5x1.5x0. No description of the wound beds, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. -The 10/3/15 skin check stated the resident had existing pressure areas. Pressure areas were listed as the left and right gluteal fold and the left and right heels. The form stated Resident has large open area to right gluteal fold and small deep open area to the left gluteal folds. No measurements or staging was recorded for any wound. No description of the wound beds, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. 3. Daily Skilled Nursing Notes Daily skilled nursing notes in the electronic record were reviewed for each day that a note was documented. The skilled notes provided a place for nurses to document specific skin concerns including a place to document free text notes and a body map with a table where location and measurements of wounds and stage of wounds could be tracked. Review of the skilled notes revealed inconsistent documentation regarding the location of the resident's wounds, failure to document the presence of wounds, and failure to note changes to the resident's wounds. a. May 2015 -When wound location was recorded, the location most often recorded as having a wound was the right buttock. (See above for documentation that the resident was admitted with a stage IV pressure ulcer to his left buttock) -The 5/19 (admission) note stated the resident had one pressure wound to the coccyx. No measurements for further description was included in the note. -On 5/25, 5/26, and 5/28 no documentation related to the wound was present. -On 5/29/15 2:28 p.m., the note stated, Wound measurements taken by wound RN and wound vac changed per orders. No s/sx (signs or symptoms) infection noted. Resident denied discomfort. -On 5/30/15 10:13 a.m., the note stated, continues with wound vac to right buttocks, with minimal drainage noted at this time, no oder. (Sic) -Measurements, staging, descriptions of the wound condition were not documented in the notes. -Documentation about the resident's wound vac was absent from most notes. b. June 2015 - When wound location was recorded, the location most often recorded as having a wound was the left trochanter. (See above for documentation that the resident was admitted with a stage IV pressure ulcer to his left buttock) -On 6/14 the wound vac was noted to be in place on the resident's right hip. -On 6/18 the wound was noted to be on the sacrum and the wound vac was noted to be in place. -On 6/20 the wound was noted to be on the resident's right rear thigh with a wound vac in place. -No documentation of the wound was present on 6/16, 6/17, 6/19, 6/28, and 6/30/15. -Measurements, staging, descriptions of the wound condition were not documented in the notes. -Documentation about the resident's wound vac was absent from most notes. c. July 2015 -When wound location was recorded, the location most often recorded as having a wound was the left trochanter. (See above for documentation that the resident was admitted with a stage IV pressure ulcer to his left buttock) -The 7/9/15 at 10:30 a.m., note stated, rash to right buttocks, [MEDICATION NAME] ordered, wound vac on hold, wet to dry dsgs (dressing) done. -The 7/13 at 10:05 a.m., note stated there was a new pressure area to the right gluteal fold. -On 7/25 and 7/26 the notes stated the resident had a pressure area to the left lower leg. No additional information about this new wound was found; the left lower leg wound was not recorded as present on any other days that month. - No documentation of the wound was present on 7/2, 7/3, 7/10, 7/14, 7/15, and 7/31/15. -Measurements, staging, descriptions of the wound condition were not documented in the notes. -Documentation about the resident's wound vac was absent from most notes. d. August 2015 -When wound locations were recorded, the locations most often recorded as having a wound were the left and right gluteal folds/buttocks, and the left heel. -On 8/5/15 the record showed the presence of a left heel pressure ulcer. No additional information about the ulcer was documented. Presence of a left heel pressure ulcer was also noted on 8/13, 8/14, 8/18, 8/19, 8/20, 8/28, 8/29, 8/30, and 8/31/15. -On 8/9/15 at 1:55 p.m., the note documented a right heel pressure ulcer. No additional information about the ulcer was documented. -The 8/20/15 at 8:15 p.m., note stated, Dressings to bil(ateral) gluteal fold open area are changed per order after shower. Dressings clean, dry and intact. No s/s of infection noted. No drainage or odor noted. -On 8/27/15 at 2:51 p.m., the note documented the resident had a blister to the right heel. Presence of a right heel pressure ulcer was documented on 8/28 and 8/29/15. -No documentation of the wounds was present on 8/2, 8/3, 8/7, 8/8, 8/10, 8/11, 8/12, 8/15, 8/21 and 8/26/15. -Measurements, staging, descriptions of the wound condition were not documented in the notes. -Documentation about the resident's wound vac was absent from most notes. e. September 2015 -When wound locations were recorded, the locations most often recorded as having a wound were the left and right gluteal folds/buttocks and the right and left heel. - No documentation of the wounds was present on 9/3, 9/4, 9/5, 9/7, 9/12, and 9/18/15. -Measurements, staging, descriptions of the wound condition were not documented in the notes. f. October 2015 -The 10/2/15 at 10:37 a.m., note showed the resident had two coccyx wounds. They were not identified as left or right ulcers. The stage IV coccyx ulcer measured 7x8x2.5 and the stage III ulcer measured 3x3x4. No documentation related to the heel wounds was included in the note. No documentation related to the wound condition, drainage, odor or other pertinent wound data was recorded. -The 10/9 note stated that the resident had wounds to his left and right trochanter. -No documentation related to the resident's wounds were present on 10/1, 10/7, 10/8, 10/10, and 10/11/15. C. Nurse's Notes A review of nurse's notes from 5/19/15 through 7/12/15 revealed no documentation of measurements of the resident's left buttock wound or changes to the condition of the wound since admission. A 7/13/15 at 2:40 p.m., nurse's note showed the resident had a new open area to the right gluteal fold. The physician was notified and treatment was started. A 7/13/15 situation background assessment recommendation (SBAR) nurse's note stated the resident had a new pressure area to this right gluteal fold. The note stated the resident had been sitting up in his chair too long. A 7/16/15 at 3:51 p.m., nurse note stated the resident requested to be sent to the hospital. The resident had a temperature of 101.3 and pulse of 140. An elevated white cell count of 29.8 was noted on the resident's labs. An order was received to send the resident to the hospital. A 7/25/15 at 2:28 a.m., note stated the resident has returned from the hospital. The resident was on intravenous antibiotics and was on isolation for a drug resistant wound infection. A review of nurse's notes from 7/26/15 through 8/7/15 revealed no documentation of the resident's wound measurements, changes to the left or right buttock wound condition. An 8/7/15 note did reveal the resident had been out of the facility that day for an unsuccessful home evaluation. Nothing was documented on 8/8/15 in the nurse's notes about the worsened right gluteal fold pressure ulcer (see above skilled nurse's note) An 8/14/15 at 4:22 pm., note stated the resident's wound vac was discontinued because of frequent bowel movements which necessitated too frequent change of the wound vac. An 8/28/15 and 8/29/15 note stated the resident had wound care to the right and left gluteal folds and to the left heel. A 9/2/15 nurse's note stated the resident had wound care to both gluteal wounds and to bilateral heels. A 9/6/15 nurse's note stated the resident had wound care to both gluteal wounds and to bilateral heels. A 9/10/15 nurse's note stated the resident was in bed and not feeling well. Subsequent nurse's notes through 9/13 showed the resident continued to decline and had a change in cognition. A 9/17/15 at 3:08 p.m., note stated the resident returned from the hospital. The resident was again alert and oriented. A 9/17/15 at 5:41 p.m., note stated resident has pressure area to right heel, hard dry and intact, pressure area to left heel opened with hard dry surrounding, edges a little moist and macerated, minimal drainage noted, area to left gluteal fold open, clean wound bed, vac applied, open area to right gluteal fold with slough noted to base, edges a little red, wound vac applied. A 9/17/15 at 6:20 p.m., note stated the resident needed to be repositioned frequently from side to side for to prevent additional pressure wound areas. A 9/29/15 at 9:41 a.m., note stated the resident was out of the facility for an appointment with the wound clinic. A 10/4/15 at 9:45 a.m., note stated the scab to the resident's left heel fell off. The skin below was moist, pink and intact. The plan was to continue sure prep to the heel for [MEDICATION NAME]. A 10/10/15 at 6:50 p.m., note stated that the resident's skin around wound vac site was irritated due to frequent changing necessitated by the wound vac's contamination with stool. The resident was noted to have multiple bowel movements each day. D. Nursing Admission Data Collection Form The 7/23/15 form showed the resident was readmitted to the facility from the hospital with pressure ulcers to the right gluteal fold (see above; acquired in facility 7/13/15) and the left trochanter (present on original admission 5/19/15 as left buttock). No measurement, staging, description of any wound condition were documented. The 9/17/15 form showed the resident was readmitted to the facility with pressure areas to the left gluteal fold, right gluteal fold, right heel and left heel. No measurement, staging, description of any wound condition were documented. E. Telephone Orders Review of telephone orders confirmed the IDT failed to request a therapy referral to evaluate the resident's mattress, wheelchair or wheelchair cushion as the resident developed new ulcers on his buttocks and heels. Further review revealed delay in seeking treatment orders for newly acquired ulcers. A 7/13/15 order stated cleanse open area to right gluteal fold with wound cleanser, pat dry, apply wound gel, cover with foam dressing change every day. Even though the wound had increased in size on 8/8/15. there was no telephone order evidencing a change in wound treatment or request for a PT referral to address the resident's need for pressure relief to his buttocks, now with ulcers on the right and left buttock An 8/14/15 telephone order stated that the wound doctor needed to consult the infectious disease doctor for a plan of care for the resident's wounds. An 8/14/15 telephone order directed a wound vac change ever Monday, Wednesday and Friday and as needed to the right buttocks. The wound vac was to be set at 125mm of suction. An 8/14/15 telephone order directed cleanse left gluteal fold with wound cleanser, pat dry, place wet to dry dressing then cover and secure with tape. Change twice daily for wound care. An 8/26/15 note stated the resident needed to have an appointment with the wound clinic for the right and left gluteal fold wounds and the left heel wound. Again, there was no evidence a referral was requested for therapy to evaluate the resident's mattress, wheelchair or wheelchair cushion An 8/28/15 telephone order directed staff to cleanse right ischium with wound cleanser, apply [MEDICATION NAME], and apply foam dressing daily. An 8/28/15 telephone order directed staff to cleanse right gluteal fold with wound cleanser, pat dry, apply Santyl ointment, and cover with foam dressing once daily. An 8/28/15 telephone order directed staff to cleanse left heel wound with wound cleanser, pat dry, apply sure prep to skin around open area, and apply wound gel to open area then cover with border gauze once daily for wound care. A wound to the left heel was initially identified on 8/5 and then again on 8/13, 8/14, 8/18, 8/19, and 8/20/15. (See skilled nursing documentation above) An 8/28/15 telephone order directed staff to apply sure prep to intact blister on right heel twice daily for wound care. A wound to the right heel was first identified on 8/9 and then again on 8/23 and 8/27. A 9/4/15 telephone order directed staff to send the resident to the wound clinic for an evaluation and treatment. A 10/9/15 telephone order directed staff to send the resident for a surgical consult for a diverting [MEDICAL CONDITION] to help with the healing of his gluteal pressure ulcers. F. Treatment Administration Record (TAR) The 5/15 TAR showed an order for [REDACTED].

Based on record review and interviews, the facility failed to provide evidence all alleged violations involving mistreatment, abuse, neglect and exploitation (MANE) were thoroughly investigated for five (#82, #44, #51, #76, and #133) of nine out of 47 total residents sampled. Specifically, the facility failed to ensure all alleged violations were timely reported, thoroughly investigated and steps were taken to protect residents from further abuse. Record review revealed violations of potential MANE continued per documentation in progress notes. Residents expressed they were fearful for their safety when residents #51 and #76 'acted out,' feared being hit by objects thrown by resident #76 and feared resident #51 and #76 would go after them. Cross-reference F309; quality of care; failure of facility to understand and address resident #51 and resident #133's behaviors. F323; accident hazards; failure of facility to protect residents from resident to resident abuse. The findings include: I. Facility Policies: In pertinent part: The 6/13 Abuse and Neglect Prohibition policy revealed: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property .Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator and/or Director of Nursing. The 6/13 Incident/Accident Reporting for Residents indicated: All incidents, accidents, and unusual occurrences involving a resident are documented and reported. All incidents considered to be or have the potential to be, significant and/or serious are reported timely to the facility Administrator (abuse coordinator) and to Risk Management and in accordance with any federal and state law. The facility thoroughly investigates any such incident. II. Facility failure to thoroughly investigate and protect residents for abuse A. Resident #51 1. Resident #51, age 77, admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. He was transferred to the hospital for a psychiatric evaluation on 7/10/15, but returned to the facility the same day. The 6/8/15 MDS revealed the resident's cognition was severely impaired with a brief interview of mental status (BIMS) score of one out of 15. Section C (Cognitive Status) identified the resident presented with behaviors of inattention and disorganized thinking. Section E (Behaviors) indicated the resident had hallucinations and delusions. The resident's overall presence of behavioral symptoms was not filled out to determine how the resident ' s behaviors impacted the resident or others although behavioral symptoms were present. Section E further showed on a daily basis, the resident had physical and verbal behavioral symptoms directed toward others. The 9/3/15 MDS did not identify any hallucinations or delusions in section E. The assessment did report physical and verbal behavioral symptoms occurred one to three days. The presence of the behavioral symptoms according to the assessment did not impact the resident or put him as risk for physical illness or injury; did not significantly interfere with his care; did not significantly impact others or put others at risk for physical injury; did not disrupt care or living environment. The 3/28/15 behavior care plan, revised on 4/12/15, identified the resident had been verbally and physically aggressive to staff and other residents. The resident displayed poor impulse control and anger. The resident had a history of [REDACTED]. -The goals were the resident would have zero to one episode per day through the next review date. The resident's aggressive behaviors would be minimized with intervention through next review period as evidenced by no harm to self or others. -The interventions listed to address the resident's behaviors were: administer medications as ordered; observe/document for side effects and effectiveness; analyze time of day, places, circumstances, triggers, and what de-escalates behavior and document; assess and address for contributing sensory deficits; assess and anticipate resident needs: food, thirst, toileting, comfort level, body positioning, pain; give resident as many choices as possible about care and activities; observe/document/report as needed any signs or symptoms of resident posing danger to self and others; psychiatric/psychogeriatric consult as indicated; when resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk away calmly, and approach later. There were no new interventions listed after 3/29/15 although the resident had ongoing behaviors between 7/10/15 - 9/13/15. 2. Allegations involving MANE toward residents and staff On 10/6/15 at 3:09 p.m., resident #101, who was alert and oriented per his 7/13/15 MDS assessment, was interviewed. He stated there were times in the facility he felt mentally and emotionally distressed. He stated there was an incident when resident #51 grabbed the fire extinguisher in the main dining room to use as a weapon. He said he witnessed the resident hit people. He stated the resident also grabbed a facility mailbox to use as a weapon. On 10/6/15 at 5:50 p.m., resident #82, who was alert and oriented per her 8/4/15 MDS assessment, was asked about concerns or problems with a roommate or any other residents. The resident stated, It's (resident #51). Residents are fearful of him. He can respond in a logical way, but other times he just goes off .He tends to target women. I've seen his handprint on staff . The resident continued, A few months back he wanted to go out so I slipped past him and went out the door. I couldn't get back in because he was swinging the mailbox .It was such a frightening moment .I don't have a lock on my door. I don ' t feel safe . On 10/7/15 at 2:39 p.m. a certified nurse aide (CNA) #18 was interviewed. The CNA confirmed there had been an incident when resident #51 was agitated in the dining room and obtained a fire extinguisher to use as a weapon. The CNA recalled the resident punched a staff member in the chest and resident #51 had to be removed from the dining room. On 10/7/15 at 3:30 p.m., a licensed practical nurse (LPN) #7 was interviewed. The LPN confirmed resident #51 had dementia and was combative at times. She said she had been a victim of resident #51's aggressive behavior. The LPN acknowledged the resident had pulled the pin from a fire extinguisher and had hit a number of people including the LPN in the dining room. The LPN stated a police report was filed. On 10/8/15 at 9:46 a.m., CNA #5 was interviewed. The CNA stated resident #51 has grabbed the fire extinguisher to use as a weapon more than once. The CNA said the resident was combative and he, too, had been a victim of the resident's aggressive behavior. He stated residents have reported to him they feel scared when resident #51 is seen exhibiting such behaviors. The CNA further shared it was not safe for resident #51 to grab hold of fire extinguisher as he could spray himself with contents. The CNA reported he informed the floor nurses when residents reported they were scared or afraid. On 10/8/15 at 10:14 a.m., CNA #20 was interviewed. The CNA said residents have told her they do not feel safe when resident #51 acts out. On 10/8/15 at 1:26 p.m., LPN #2 was interviewed. She reported incident reports (situation/background/assessment/recommendations -SBAR) were completed for aggressive behaviors by residents towards staff and other residents that endangered their safety. The LPN did not identify any other steps that would be taken under such circumstances, such as notifying the director of nursing (DON) or nursing home administrator (NHA) after incident reports were completed in the facility's electronic medical record. The LPN stated she was hit by the resident and a police report was filed. On 10/8/15 at 1:41 p.m., LPN #5 was interviewed. She stated nurses were expected to report to the NHA or DON events such as skin tears, falls, scratches, behaviors, unknown bruises and any kind of elopement; she did not identify that behaviors which endanger residents and staff should be reported. . On 10/8/15 at 4:01 p.m., resident #101 was interviewed again. He stated he felt resident #51 was violent. He stated he felt he and other residents at the facility were in danger when the resident acted out and some residents felt the resident could go after them. The resident stated during the time he was recovering from an accident, he felt resident #51 could have easily hurt him. The resident did not feel the facility had the accommodations to meet the needs of resident. The resident felt the facility did not provide adequate reassurance to residents after violent outbursts observed by residents at the facility. 3. Record Review a. Progress notes A review of resident #51's progress notes 7/10/15 - 9/13/15 revealed: -On 7/10/15, resident #51 threw trays into a crowded dining room, pulled the fire extinguisher off the wall and tried to hit people. -On 7/14/15, resident #51 hit the front glass door with the big black mail box. The notes indicated the resident physically and verbally assaulted a staff member and swung at police officers. - On 7/21/15, an at-risk resident review (ARR) met for discussion of the resident's behaviors of aggression and most recently verbal sexual behavior towards staff. The facility was considering an all male dementia unit and waiting on a response. The resident was going to continue to be followed in weekly ARR. However, there were no ARR notes prior to 7/21/15 to address resident behaviors and there were no ARR notes following the resident after 7/21/15 although inappropriate behaviors continued to be seen. Specifically, progress notes revealed the resident continued to exhibit unsafe, aggressive, and inappropriate behaviors on 7/15/15, 7/18/15, 7/20/15, 7/22/15, 7/23/15, 7/30/15, 8/7/15, 8/12/15, 8/15/15, 9/7/15, 9/8/15, and 9/13/15. (Cross refer to F309; quality of care). (2) Investigation On 10/8/15 at 3:10 p.m., the NHA, consultants (Conslt) #1 and #2, and DON provided the following SBAR and progress notes as evidence of their investigation of the 7/10/15 incident. - The SBAR communication form dated 7/10/15 related to resident #51 read in pertinent part: The SBAR identified a change in the resident's status because he was combative. The things which made the resident's condition worse was trying to stop him from going where he wanted and doing what he wanted to do. The thing which made the resident's condition and symptoms better was an anti-anxiety medication, [MEDICATION NAME]. The SBAR revealed the resident's combative behavior had occurred before and the treatment for [REDACTED]. The SBAR stated the resident had new or worsening behavioral symptoms and the resident was physically aggressive and needed antipsychotic medications and medication management. The report stated the resident was transferred to the hospital for a (psychological) evaluation and further noted the resident was having increasingly frequent episodes of physical aggression. No police reports were provided. -Progress notes from 7/10/15 to 7/11/15. In pertinent part: Resident was being transferred to hospital for uncontrollable violent behavior .he continued to be physically aggressive and had to be pulled from the door way so kitchen staff could lock the kitchen door .the resident started to throw trays and trash can into the crowded dining room. When all throwable objects were removed from his reach, he pulled the fire extinguisher off the wall, and tried to hit people with it, then pulled the pin and was about to discharge it when another staff member came up behind him and was able to pull it from his hands. He continued to physically assault staff while he was being wheeled to his room. Once in his room, he started throwing things (then) charge staff. He chased staff down the hall throwing whatever he could get to. Residents had to be taken to another area for (their) safety. Resident was sent to the hospital for a psychological evaluation. .resident had behavior issue and upon arrival resident was seated in wheelchair swinging clinched fists, and kicking at staff .resident grabbed box of gloves and threw them at the DON (director of nurses) .resident grabbed staff ' s wrist and struck nurse in upper abdomen police arrived as resident entered the common area .resident cursing and attempted to strike officers; officers were able to talk resident down without use of force and resident taken to hospital for psychological work up. 3. Failures in the facility's response to violations involving MANE No investigations were provided for the incidents documented in the progress notes on 7/14/15, 9/4/15 and 9/13/15, see above. There was no further discussion of the resident's behaviors in the ARR although per the 7/21/15 note, the resident was to be discussed weekly (see above). Resident #82 (see above) stated in her interview on 10/6/15, that she wrote a long letter on 7/15/15 about the incident with resident #51 swinging the mailbox and how it made her fearful, made a copy of it, and then put the copy of the letter into the grievance box which was located outside the administrator's office. The resident showed the letter to the surveyor. The resident stated, They never got back to me. Regarding the incident on 7/10/15, the facility failed to provide any witness statements or interviews from residents or staff regarding the incident and their response to the incident. There were no summary findings of an investigation; the facility failed to document actions taken in response to the findings (other than hospitalization ). The SBAR did not discuss the resident ' s environment, predisposing factors, interventions, or attempt to identify root causes. There was no evidence the facility discussed the steps that would be taken to keep residents safe when resident #51's behaviors escalated. On 10/8/15 at 3:10 p.m., the NHA, consultant (Conslt) #2, and DON were interviewed. -The NHA said the facility attempted to hospitalize the resident after the 7/10/15 incident but the mental health hospital was unable to take the resident. The NHA did not indicate any other mental health supports were pursued in an effort to educate staff how to effectively and consistently intervene to address resident #51's behaviors and to keep other residents safe from harm. -The DON confirmed there was no interdisciplinary note (IDN) to show the facility discussed the incident, the resident's behaviors, or a safety plan to protect residents from physical and mental abuse by the resident, after the 7/10/15 incident or after the incidents that followed on 7/14, 9/4, and 9/13/15 (see progress notes above) . -Conslt #2 stated the facility attempted to protect residents and isolate resident #51 as he acted out on 7/10/15.; however, the resident did not have interventions on his behavior care plan updated since 3/29/15. He stated the facility attempted to de-escalate the situation, although specific interventions were not articulated or provided for review. He stated the immediate response of the facility was to send the resident out of the facility but offered no other interventions to ensure residents' ongoing safety from resident #51 aggressive behaviors. On 10/13/15 at 4:00 p.m., a registered nurse (RN) #1 was interviewed. She stated she hasn't been asked to discuss the resident's behaviors and hasn't been given any specific interventions to help de-escalate the resident when inappropriate behaviors are seen. She stated she was unaware of effective interventions determined by the facility's management team to assist the resident. She said because she was unfamiliar with how to intervene in resident behaviors, she was not able to direct CNAs on proper techniques to help the resident and situation. The RN stated she and other floor staff used a 'trial by fire approach' when resident #51 acted out and had to be calmed. The RN stated the facility management team was responsible for identifying problems and approaches but the facility did not have any management to discuss resident issues effectively and consistently. The RN stated there were still a few residents leery of resident #51. B. Resident #44 1. Resident #44, age 52, entered the facility on 3/23/15. The facility face sheet indicated the resident was admitted with [DIAGNOSES REDACTED]. The 9/14/15 Minimum Data Set (MDS) revealed the resident ' s cognition was moderately impaired with a brief interview for mental status (BIMS) score of 12. Section G (Functional Status) indicated the resident had limited range of motion of upper and lower extremities to both sides. On 10/6/2015 at 3:26 p.m., resident #44 was interviewed. He reported that because of his ALS and MS, he was dependent on someone to assist him with all cares. The resident stated he was not able to move his arms or legs; he needed total assistance. He said he had a touch pad call light to alert staff when assistance was needed. 2. Allegation of potential violations involving MANE On 10/08/15 at 4:01 p.m., resident #44 said the other night a female resident (resident #133) with known behaviors entered his room unexpectedly and uninvited while he was in bed, took his call light, wrapped the cord around her neck and almost knocked over his large flat screen television. The resident stated he was scared the resident was going to jump into his bed and he was unable to do anything to help himself. He stated there was another resident who entered his room when he was sleeping at times and would stare at him. He stated it was creepy to see a resident staring at him. On 10/08/15, the resident's roommate, resident #101, who was alert and oriented per 7/13/15 MDS assessment, was interviewed at 4:10 p.m. Resident #101 stated he reported the above incident to the evening nurse (Licensed Practical Nurse #3). He stated the uninvited resident also walked in on him while he was urinating in the restroom and entered another person's room afterward. Resident #101 stated no one has spoken to him about the incident and what he had witnessed involving resident #44. 3. Record Review: A review of the resident #44's progress notes from 10/6/15 through 10/13/15 failed to show any documentation related to the incident involving a female resident entering the resident's room uninvited and the resident feeling scared the female resident would jump in bed with him. 4. Staff Interviews - failure to promptly report allegation On 10/8/15 at approximately 4:20 p.m., conslt #1 and conslt #2 were informed of the incident reported by resident #44 and #101. Conslt #1 stated she was not aware of the incident and would follow-up. Documentation regarding the incident was requested. On 10/8/15 at approximately 4:45 p.m., conslt #3 stated she was not aware of an incident involving the uninvited resident and resident #44. Conslt #3 stated the resident's degree of ALS prevented him from moving his extremities. She stated she would look into an intervention allowing the resident to feel safe and protected from individuals entering his room. d. Facility Follow-up On 10/9/15 at 3:45 p.m., conslt #1 provided a copy of a incident/accident report dated 10/6/15. The conslt reported the incident report was a late entry and was actually completed on 10/9/15 although the event occurred on 10/6/15. The conslt stated the investigation did not take place until 10/8/15 after the facility became aware of the incident. The facility provided an investigation completed 10/9/15 which consisted of the following: -Incident/Accident Report (late entry completed 10/9/15) The findings section revealed, (A) female resident was found in (resident #44's) room (with) his call light draped around her shoulders and neck. Resident stated, (She) scared me. I thought she was gonna jump in bed (with) me. -Interview of LPN #3 dated 10/8/15. In pertinent part, .The male resident reported that she scared me because I thought she was going to jump into bed with me. The nurse did not interpret the resident's statement as being fearful but rather more along the lines of being concerned . -Interview of resident dated 10/8/15 completed by social services director (SSD). As it pertains, he was more startled to see them in his room. He wished staff would get (the uninvited residents) under control. -Questionnaire completed with resident #44. In review of the questionnaire, the resident expressed he was nervous he couldn't defend himself the other night when a resident entered his room and he did not have access to his call light. 4. Failures in facility investigation The facility did not summarize their findings, did not indicate how they planned to keep the resident safe from other residents entering his room when he felt he could not defend himself, did not obtain any witness statements or interview others regarding residents wandering into resident rooms. (See resident #44 interview below regarding additional potential violations involving MANE.) On 10/13/15 at 4:12 p.m., conslt #2 stated another investigation was conducted at the same time as the above investigation to see whether residents felt safe at the facility and to determine if there were residents who were fearful or felt in danger. He confirmed there was not any available documentation provided in the investigation folder during the survey process to refer to another investigation for statements or interviews. The conslt stated the uninvited resident listed in the allegation was no longer residing at the facility and the conslt acknowledged there was no available documentation provided in the investigation folder to indicate this. The conslt further confirmed there was no summary of the investigation, no interventions offered or planned to address the resident's safety concerns, and neither a complete nor thorough investigation of the incident and how the facility planned to prevent further incidents from occurring. 5. Additional allegations of potential violations involving MANE since 10/13/15 On 10/23/15 at 12:57 p.m. resident #44 was interviewed again. He reported resident #133 had come into his room four times the day before. He reported staff will come in and try to get her out of the room but he will frequently have to wait a long time because they are understaffed. He reported the resident will come into his room and yell and scream and say nonsense. He reported the resident had come into his room the day before four times; once during the day and three times at night. He reported he had witnessed the resident swinging at staff when they had tried to get her out of his room and it made him nervous. He stated, I have seen her get in a fight with another resident, I have seen her run around and hide, grab stuff off the walls, yell and say nonsense and go into other residents' rooms. When she came into my room I yelled get out and started pounding on the call light. She started coming towards me and I was scared. Cross reference F323; accident hazards/resident to resident abuse. C. Resident #76 Resident #76, age 73, admitted into the facility on [DATE] and readmitted again on 1/21/15 with [DIAGNOSES REDACTED]. The 10/6/15 MDS revealed the resident was unable to complete a brief interview for mental status and staff completed on the resident's behalf. The staff assessment for mental status (SAMS) identified the resident had short and long term memory problems although the resident had the ability to recall current season, location of own room, staff name and faces, and that she resided in a nursing home. The resident had signs and symptoms of [MEDICAL CONDITION] with continuous disorganized thinking and fluctuating inattention and altered level of consciousness behaviors. 1. Allegations involving MANE On 10/6/15 at 3:09 p.m., resident #101 was interviewed. He stated there were times in the facility he felt mentally and emotionally distressed. He stated resident #76 routinely threw items in the dining room with residents present when she was upset. He stated when the resident was in a bad mood, residents had to protect themselves because the staff allowed the resident to act out instead of dealing with the resident ' s behaviors. The resident stated he reported these events to staff. The resident was concerned about the behaviors observed by resident #76. On 10/7/15 at 2:39 p.m., CNA #18 was interviewed. The CNA confirmed resident #76 was known to throw dishes and become agitated in the dining room. On 10/8/15 at 9:46 a.m., CNA #5 was interviewed. He stated he saw resident #76 throw cups in the dining room and verbally abuse residents in the dining room. He said residents have reported to him feeling scared when resident #76 was seen having behaviors. The CNA reported he informed the floor nurses when residents reported feelings of being scared or afraid and when residents acted out or had inappropriate behaviors. On 10/8/15 at 10:14 a.m., CNA #20 was interviewed. The CNA confirmed resident #76 threw plates in the dining room. The CNA said they did not know what triggered this behavior. She stated resident has thrown water also. The CNA stated there was a nurse on duty during each meal service. She stated the nurse was to remain in the dining room during meal service to assist and observe meal service. The CNA said residents have told her they do not feel safe when resident #76 was exhibiting behaviors. On 10/8/15 at 1:26 p.m., LPN #2 was interviewed. She said incidents reports (SBAR) were completed for falls, skin tears, and bruising, unsafe smoking behaviors, elopements and aggressive behaviors towards staff or residents; she did not indicate incident reports were completed or incidents were reported when residents expressed aggressive behaviors that had the potential to cause injury. On 10/8/15 at 1:41 p.m., LPN #5 was interviewed. She stated nurses were expected to report residents' aggressive behaviors to the NHA or DON. She said some residents have told her they were afraid of getting hit when resident #76 threw things in the dining room. On 10/8/15 at 4:01 p.m., the resident #101 was interviewed again. He stated he felt resident #76 was violent. He stated he felt he and other residents at the facility were in danger when the resident acted out and some residents felt the resident could go after them. The resident stated during the time he was recovering from an accident, he felt the resident could have easily hurt him. The resident did not feel the facility had the accommodations to meet the needs of resident. The resident felt the facility did not provide adequate reassurance to residents after violent outbursts observed by residents at the facility. 2. Record Review: a. Progress Notes A review of resident #76's progress notes from 8/19/15 to 9/13/15 revealed on 9/4/15 and again on 9/13/15, the resident was observed in the dining room throwing coffee mugs onto the floor and pouring cups of water onto the dining room tables, threw a plate at a staff member; was cursing, screaming, and throwing cups. b. Investigation On 10/7/15 at approximately 5:00 p.m., a request was made to the NHA for investigations related to resident #76 regarding the above incidents. On 10/8/15 at 3:10 p.m., the NHA, consultants (Conslt) #1 and #2, and DON provided an investigation which consisted of the following: - Progress notes from 4/2/15 through 9/19/15. In pertinent part: The 9/4/15 progress note revealed, .resident noted in her room with the door closed using foul language, then opening/closing her room door loudly and shouting/cursing; resident out of her room into the dining room collecting cups and into the main lobby collecting flower decorations and taking them to her room; noted at the coffee area in the dining room tearing open and putting numerous packets of sugar into a cup of coffee, then proceeded to throw coffee mugs onto the floor and shattering multiple mugs along with pouring cups filled with water onto the dining room tables .shaking her fists at residents while cussing and yelling . The 9/13/15 progress noted showed, .(Resident) then went into dining room and started filling up several cups with water and juice and took some back to room. (Resident) then came into the dining room requesting her tray and when staff explained to (resident) her tray was in her room; (resident) began cursing and screaming. (Resident) then threw a plate at (LPN #5). (Resident) was escorted to a table and an extra tray was given to (resident), she dumped her plate on the table and went to get more juice and started throwing the cups. (Resident) started to curse out other (residents) that were eating . c. Failure in facility investigation of allegations involving MANE The DON stated she searched the resident ' s record and could only produce the progress notes from 4/2/15 through 9/19/15. She expressed in her search for information, she could not find a single SBAR in the resident ' s medical record. The facility did not have any witness statements or interviews from staff or residents regarding the above incidents. There were no summary findings of investigations; the facility did not attempt to determine the root cause or discuss interventions or implementation of new interventions following the resident's behaviors on 9/4/15 or 9/13/15. The facility had a progress note from 9/19/15, labeled, (at risk review) (ARR) because resident had increased behaviors. There was no follow-up information, no plans to ensure residents' safety from resident #76's behaviors made available in the resident's chart after the ARR.

Based on observations, interviews and record reviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible and that residents received adequate supervision and assistance to prevent accidents. The facility's failures affected 16 of 47 sampled residents (#82, #101, #44, #51, #76, #88, #133, #66, #15, #53, #118, #7, #72, #67, #132, and #49). Specifically: I. Failure to protect residents from resident to resident abuse. A. Resident #133, who had a [DIAGNOSES REDACTED]. pre-admission evaluation given the resident's history, and without effective interventions to ensure the safety of residents from her behaviors. Prior to resident #133's emergent discharge, the facility failed to take steps to protect resident #44, who was dependent, from resident #133's behaviors. Resident #133 entered resident #44's room and removed the call light he required to summon staff. After readmission, resident #133 was documented as going in and out of other residents' rooms and through their belongings, being very anxious and unable to respond to simple commands; the resident entered resident #44's room four times, once during the day and three times at night. The facility failed to implement measures to ensure resident #133's care was individualized and effective and her supervision adequate to protect the other residents in the facility. Residents #44, #132, and #49 expressed resident #133 made them worried and fearful for their safety. B. Residents #51 and #76 exhibited aggressive, violent, and unsafe behavior in the facility common areas. The facility failed to take steps to protect residents, including resident #101, from verbal, physical, and mental abuse by residents #51 and #76. Resident #101 expressed the residents' behaviors distressed him and other residents reported to staff they feared for their safety when residents #51 and #76 acted out. The facility's failure to keep facility residents safe from resident to resident abuse created a situation of immediate jeopardy (IJ) with the potential for serious harm. II. Failure to protect against accident hazards A. Resident #88 eloped and was located 10 miles away from the facility. The facility failed to take steps to ensure resident #88 was protected from harm due to her wandering behavior; the facility failed to thoroughly investigate the incident and failed to implement interventions to prevent further elopements. B. Residents #53, #15, #7, #66, #72 were smokers and resident #67 was observed in the smoking area. The facility failed to ensure these residents were safe while smoking. C. Resident #118 utilized a heating pad. The facility failed to ensure resident #118's use of a heating pad was assessed for safety and its use adequately supervised. D. Medication carts were left unattended. The facility failed to ensure medication carts were secured. The findings include: I. Immediate Jeopardy A. Findings Triggering Immediate Jeopardy - Resident to Resident Abuse Record review and resident interviews conducted on 10/23/15 revealed resident #133 was wandering and entering other residents' rooms and personal space. Facility staff were aware of the resident's behaviors and effective interventions were not in place to assure residents of their safety. Interviews with residents #44, #132, and #49 revealed they were fearful for their safety and well being. Interviews with staff and observation of resident #133 revealed she was permitted to wander freely throughout the facility with no additional monitoring or care. Record review revealed the resident was discharged from the facility for behaviors on 10/8/15, and readmitted on [DATE] with the only change in her care being the use of Neurontin (an analgesic pain medication used for behaviors). The facility was aware of the resident's behaviors on 10/8/15 when she was initially discharged and readmitted the resident without having a clinical team reassess the resident to determine if she was appropriate for placement in the facility. On readmission to the facility, staff again were aware of the resident's continued behaviors; however, there were no interventions put in place to keep the resident and other residents safe, creating a situation of immediate jeopardy. B. Notification of Immediate Jeopardy Observations, interviews and record review revealed the facility failed to develop and implement interventions and safety measures related to resident #133's known behaviors which made residents fearful for their safety. The facility's failures were discussed with the consultants (Conslt #4, and Conslt #5) from 2:00 p.m. to 2:45 p.m. on 10/23/15. At 3:05 p.m. they were informed that the failures created a situation of immediate jeopardy with the potential for serious harm. C. Plan to Remove Immediate Jeopardy The facility's second plan to remove immediate jeopardy was submitted on 10/23/15 at 6:15 p.m. The plan read: (The facility) respectfully submits this plan of action to abate the allegations of immediate jeopardy identified on October 23, 2015. Residents living in (the facility) have the potential to be affected by this alleged deficient practice. Effective immediately, the identified wandering resident (#133) has been discharged from the center to an appropriate facility to meet her need(s) and will not be readmitted . The resident, staff, Medical Director attending physician and the staff at (the accepting emergency room ) were informed that the resident will not be readmitted to (the facility). All staff currently working at Aspen Living Center have been educated that when they see, hear or are made aware of an allegation of abuse or neglect or any resident concern around safety and or fear, they are to first make sure all residents are safe in any situation then report to the administrator. Remaining staff will be re-educated on the same process before they work another shift. Social Services met with the identified residents that alleged they were fearful of said resident. Social services informed them that the identified resident has been discharged and would not return that they are safe. Each resident responded to the social services director that they felt better and had no other fear. The Social Services Director will address the residents in the next resident council on the facility's process in reporting concerns in particular fear of other residents. The admissions team has been re-educated on the facility's admission process in where they will follow the CF AST guidelines where residents with a history of wandering or elopement, or aggressive behaviors will be brought to the clinical team prior to accepting the resident to (the facility). The administrator and or designee will review incident accident reports, concern forms, 24 hour report and the clinical dashboard in (the electronic medical records system) in each morning meeting to identify any resident to resident concerns. The administrator will bring all concerns to QA (quality assurance) weekly for one month then monthly for 3 (three) months and then quarterly or as needed to review all outcomes and applicable action plans. D. Removal of Immediate Jeopardy The facility's plan to abate Immediate Jeopardy was accepted on October 23, 2015 at 6:20 p.m. and the immediate jeopardy removed. However, deficient practice remained at a G level, actual harm that is isolated. II. Resident to Resident Abuse A. Resident #133 - Facility Failure to Protect Residents from Resident #133's Behaviors 1. Resident Status Resident #133 was a [AGE] year old admitted initially on 10/5/15, discharged to the hospital on [DATE], emergently discharged [DATE], and readmitted from a behavioral health facility on 10/20/15. According to her face sheet, her [DIAGNOSES REDACTED]. The only minimum data set (MDS) assessment available was dated 10/8/15. It noted the resident had impaired decision making skills and behaviors that were directed towards others which occurred daily. It also noted she wandered daily. A care plan for wandering, dated 10/9/15 and revised on 10/13/15, documented: .tends to wander up and down the hall, responding to external stimuli. She touches the items on the wall, at times may take something off the wall with her, or she just might admire it and feel it. This behavior makes peers uncomfortable, putting her at risk for abuse. -The interventions were, Positive reinforcement of desired behaviors, psychotropic medications as ordered, and redirection. The care plan did not describe or detail the nature of the positive reinforcement staff were to employ. The care plan did not address the resident's supervision needs, although see below, the nursing notes documented the resident required constant supervision. The care plan was not updated on the resident's readmission (10/20/15) with guidance to staff on how to address the resident's behaviors. 2. Record Review - Initial stay at the Facility 10/5/15 to 10/8/15 a. Review of the documentation from the discharging facility (admission paperwork for the facility) a discharge disposition noted, Psych Unit/ hospital. The neurological assessment comment read, Confused, possibly having visual and auditory hallucinations, patient restless, talking to self, difficulty falling (sic) directions. b. Review of the nursing notes revealed: 10/5/15: The resident arrived via w/c (wheelchair) alert to name, extremely confused cannot answer questions, easily distracted, can feed self, incontinent of b/b (bowel and bladder), ambulates with unsteady gait, requires constant supervision, unable to sign consents, numerous calls made to son, no response, resident has multiple skin tears about arms, excoriated buttocks. 10/6/15: .Woke up around 0400 (4:00 a.m.). Respirations regular and unlabored. Resident sitting on side of bed carrying on incomprehensible conversation with her water pitcher and comb, occasionally pointing to the wall and ceiling while talking. Made no eye contact with me, did not respond to me calling her name. Refuse to have her VS (vital signs) taken. Safety measures in place, bed in lowest functional position, mat at bedside, wander guard on. Report given to oncoming nurse. 10/7/15: This res (resident) has been very busy, all eve (evening) shift. Going in and out of res rooms, making several attempts to get out of facility. At about 1730 (5:30 p.m.) res was seen going out hall 6 door running, Admin (administration) followed and returned res back inside after she had slipped and fell on the sidewalk. Elbow skintear covered, res continued to exit seek the res (sic) of the eve. Unable to redirect. Frequent visual checks all eve. 10/8/15 at 7:55 p.m.: Resident sent to ER for evaluate and treat r/t (related to) hallucinations both auditory and visual: Continuous elopements from facility: To have medical work up and psych evaluation. c. Review of the only social services note from the resident's initial stay was dated 10/8/15 at 7:33 a.m. noted: .with a dx (diagnosis) of unspecified dementia with behavioral disturbances and dysphagia. She is ambulatory and able to communicate, however, most of her communication is in word salad. Writer talked with (adult protective services (APS) representative) who came out yesterday to help assess resident for needs. She is sending a doctor to come in and do a neuropsych evaluation. Writer did public aid application for resident, and (APS) took it with to push the application process through quicker. (Resident) has a tendency to constantly move when awake, walking up and down the halls almost constantly. She does let staff assist her with her ADL (activities of daily living) care. She eats with her hands, even when cued to use her utensils. Writer unable to complete (cognitive assessments) with resident as a result of her current mental status. Staff redirects her often due to the current mental status; trying different things to see if we can find something she enjoys. d. Behavioral health facility documentation (resident stay 10/8/15 - 10/20/15) The resident was emergently discharged to a behavioral health facility on 10/8/15. Review of the behavioral health facility's admission documentation revealed the following behavioral health note: Spoke with (facility) .the Director of Nursing (DON) noted that the patient had walked into another patient's room and put the call light around her neck and dancing in the room. She also reported patient had swung at a staff member and attempted to bite an EMS (emergency medical services) staff member. (Facility) noted that they have little history on the patient and believe there may be a mental health history with psychosis more so than dementia. The mental status exam conducted at the behavioral health facility, dated 10/12/15, noted the resident was euphoric, irritable, angry, anxious, paranoid with delusions and obsessions. 3. Record Review - Readmission to Facility on 10/20/15 to Discharge on 10/23/15 a. Review of nursing notes revealed in their entirety: 10/20/15 at 9:25 p.m.: This res arrived via BEo (sic) at 1800 (6:00 p.m.), very anxious and unable to respond to simple commands. Has spent this shift walking in and out of other res rooms, has been found going thru other res belongings, Unable to redirect this res, multiple attempts by multiple staff. Res has no concept of personal space or no (sic). This res was seen in the dining room at evening bingo with her hands on a residents (sic) chair and tried to pull it away, with the res in it. This res then stood up and grabbed her cane and as going to hit this res and was intercepted by staff. This res has been one-one for most of this shift. 10/20/15 at 9:48 p.m.: Wandergaurd was placed on left ankle at 1830 (6:30 p.m.) due to res constant wandering and pushing and pulling on any and all doors. 10/23/15 at 4:25 p.m.: Received order from (nurse practitioner) to transfer resident to (sic) ER for evaluation and treatment. b. Record review revealed resident #133 was readmitted [DATE] with a new medication, Neurontin 300 mg PRN (as needed) for anxiety/agitation. The resident was noted as receiving Neurontin 300 mg PRN (as needed) once on 10/21/15 for anxiety/agitation, once on 10/22/15, and once on 10/23/15 (noted as ineffective). c. An incident form referring to resident #133 was found during record review of resident #132's chart. (The form did not involve resident #132 but was mistakenly placed in the wrong chart.) The incident form was dated 10/21/15 and noted It was reported to this nurse that patient took another pts jacket and was walking around when the other patient tapped (resident #133's) upper area with cane no injury noted no bruising noted. There was no follow up or assessment found regarding the incident. d. The sole social services progress note was written after the order to send the resident to theER on [DATE]. At 4:36 p.m. the social services director (SSD) noted, Writer sat with (resident) today as she was wandering through the halls more than she had been since her return from the hospital. Writer redirected her from peers rooms, and offered her something to drink on numerous occasions. She is confused, but shows no signs of aggressive behaviors. She is being transported to the hospital and staff sat with her until the paramedics arrived. e. A telephone order was written on 10/23/15 at 3:30 p.m. ordering, Transfer resident to ER for eval/clearance for psych hospitalization . Resident is danger to self and others. 4. Observations of resident #133 On 10/23/15 resident #133 was observed walking down the 300 hall. She was talking to herself and wringing her hands. On 10/23/15 the resident was observed pacing down the 300 all. When asked her name, she was able to clearly state her name, then she began making loud noises and stating, tutty fruity, and clapping. She held the arm of the surveyor and walked down the hall and said they had to get him in, while leading the surveyor. After a few steps she clapped and turned around and walked the opposite direction. On 10/23/15 at 2:00 p.m. the resident was observed pushing on the locked door at the end of the hall and pushing the buttons on the key pad. She turned around at 2:03 p.m. and began walking up the hall. She said hello and when asked how she was doing, she began to say words that were unrecognizable. She was then observed walking over to the nurses ' cart where she grabbed a metal container filled with ice and pudding and began banging it loudly on the top of the medication cart, saying other unrecognizable words. Two staff members approached the resident and asked the resident to walk with them and stated we will get you some pudding. 5. Resident interviews - Fear of resident #133 a. Resident #44 Resident #44, age 52, entered the facility on 3/23/15. The facility face sheet indicated the resident admitted with [DIAGNOSES REDACTED]. The 9/14/15 MDS revealed the resident's cognition was moderately impaired with a BIMS score of 12. Section G (Functional Status) indicated the resident had limited range of motion of upper and lower extremities to both sides. On 10/6/15 at 3:26 p.m., resident #44 was interviewed. He reported because of his ALS and MS, he was dependent on someone to assist him with all cares. The resident stated he was not able to move his arms or legs; he needed total assistance. He said he had a touch pad call light to alert staff when assistance was needed. (1) Initial allegation of unexpected, potentially unsafe behavior in resident #44's room involving resident #133. On 10/08/15 at 4:01 p.m., resident #44 said the other night a female resident, resident #133, with known behaviors entered his room unexpectedly and uninvited while he was in bed, took his call light, wrapped the cord around her neck and almost knocked over his large flat screen television. The resident stated he was scared the resident was going to jump into his bed and he was unable to do anything to help himself. He stated there was another resident who entered his room when he was sleeping at times and would stare at him. He stated it was creepy to see a resident staring at him. The resident's roommate, resident #101, who was alert and oriented, was interviewed at 4:10 p.m. Resident #101 stated he reported the above incident to the evening nurse (LPN #3). He stated the uninvited resident (resident #133) also walked in on him while he was urinating in the restroom and entered another person ' s room afterward. Resident #101 stated no one has spoken to him about the incident and what he had witnessed involving resident #44. Staff Interviews revealed the incident involving resident #44 and resident #133 had not been reported to administration as of 10/8/15, and therefore, no steps had been taken to address resident #44's concern for his safety. On 10/8/15 at approximately 4:20 p.m., conslt #1 and conslt #2 were informed of the incident reported by resident #44 and #101. Conslt #1 stated she was not aware of the incident and would follow-up. Documentation regarding the incident was requested. On 10/8/15 at approximately 4:45 p.m., conslt #3 stated she was not aware of an incident involving resident #133 and resident #44. Conslt #3 stated the resident's degree of ALS prevented him from moving his extremities. She stated she would look into an intervention to allow the resident to feel safe and protected from individuals entering his room. On 10/9/15 at 3:45 p.m., conslt #1 provided a copy of a incident/accident report dated 10/6/15. The conslt reported the incident report was a late entry and was actually completed on 10/9/15 although the event occurred on 10/6/15. The conslt stated the investigation did not take place until 10/8/15 after the facility became aware of the incident. Cross reference F225; the facility investigation failed to reveal interventions were offered or planned to address the resident's safety concerns and was neither a complete nor thorough investigation of the incident and how the facility planned to prevent further incidents from occurring. (2) Subsequent allegations of unexpected, potentially unsafe behavior in resident #44's room involving resident #133 Resident #44, was interviewed on 10/23/15 at 12:57 p.m. He reported resident #133 had come into his room four times the day before, once during the day and three times at night. He reported staff would come in and try to get her out of the room, but he would frequently have to wait a long time because they were understaffed. He reported the resident would come into his room and yell and scream and say nonsense. He reported he had witnessed the resident swinging at staff when they had tried to get her out of his room and it made him nervous. He stated, I have seen her get in a fight with another resident, I have seen her run around and hide, grab stuff off the walls, yell and say nonsense and go into other residents' rooms. When she came into my room I yelled get out and started pounding on the call light. She started coming towards me and I was scared. Certified nurse aide (CNA) #21, who had worked the previous night on resident #44's hall, was interviewed on 10/23/15 at 9:18 p.m. He reported he was aware of a female resident who went into other residents' rooms throughout the facility who lived on the next hall. He reported he had not seen that resident on resident #44's hall the night before. b. Resident #132 Resident #132, the roommate of resident #133, was an [AGE] year old admitted to the facility on [DATE]. According to her face sheet her [DIAGNOSES REDACTED]. The resident's record revealed she had been admitted to hospice care at the facility. Observation of the resident on 10/23/15 at 1:46 p.m. revealed her daughter was at her bedside and the resident was easily understood. The daughter and resident stated the roommate (#133) was constantly talking to herself and wandering into resident #132's space. The daughter stated the facility had said they were waiting for alternate placement for resident #133 and they would be transferring her out soon. The resident stated that her roommate had not tried to hurt her that she was aware of; however, her roommate's behavior had been so odd the resident was worried something 'bad' may happen. The daughter and resident stated the facility had placed the bedside table in the high position to block the roommate (resident #133) from getting to the resident, and a CNA had placed a wheelchair against the bathroom door to prevent another wandering resident from entering through the shared bathroom. The daughter stated the hospice nurse had been in the room and had to redirect resident #133 away from her mother that day. c. Resident #49 On 10/23/15 at 1:54 p.m. resident #49's room was approached and the door was found to be blocked from the inside with a chair. After knocking several times, the resident's roommate moved the chair from the doorway and opened the door. Resident #49 stated the chair was placed in the doorway to prevent that woman (resident #133) from coming into the residents' room. Resident #49 stated the night before last she heard resident #133 in the hall and resident #133 came into the residents' room and yelled, Does anyone want to get up, want to know about? The resident stated she had reported the issue to the customer service coordinator (CSC) the previous day. She had given all good reviews about the facility, but told the CSC they needed to work on resident safety. The resident had not heard any response to her concern about safety, and she stated she was afraid of resident #133 and wished they would do something. The resident stated the staff had seen resident #133 come up to her when she was at a medication cart receiving her medications from the nurse. Resident #133 started going through her bag that she had on her walker and when she told her to stop, resident #133, Threw her chest out, it was aggressive. The nurse had redirected resident #133, but she was still afraid. In an interview on 10/23/15 at 3:28 p.m. with the CSC, Nursing Home Administrator (NHA), and assistant director of nursing (ADON), the CSC responded resident #49 had recently completed a satisfaction survey and the resident had not shared any concerns with her but had given all positive responses to the interview. She said the resident had reported the other night someone had popped her head in and said, are we ready to get up in here. Resident #49 had stated that it startled her. The CSC had not reported that to anyone else. 7. Facility failure to assess resident #133 for appropriate placement and safety prior to readmission 10/20/15 and failure to implement new interventions once readmitted . An interview was conducted on 10/23/15 at 3:28 p.m. with the NHA, CSC and At DON. -The CSC stated she had received a call (10/20/15) from the behavioral health hospital where resident #133 had been admitted on [DATE], asking if they could readmit the resident. The behavioral health hospital stated the resident was ready to come back to the facility. The CSC said the SSD had done the resident assessment. -The NHA stated the SSD sent him a text message that the resident seemed to be appropriate to return to the facility. There had been no additional discussion about the resident's behaviors; at that point, the appropriateness of the resident's readmission would have been referred to clinical staff. The NHA stated the director of nursing (DON) would be the appropriate one to talk to. An interview with the DON on 10/23/15 at 8:31 p.m. revealed she had been on vacation when the resident was readmitted . She said that usually, she would be the one who would review the clinical piece of an admission; however, with her gone, it would have fallen to administration to review the admission. She stated she would not have taken resident #133 back because on her first admission, the resident had needed calming down immediately; she said she had sat in the dining area talking to the resident one on one and calming her down, and the resident had put a checker piece in her mouth which the DON had to get the resident to spit out. She stated that she was not made aware of the incident on 10/21/15 (see documentation post readmission above) and had not seen the incident form until it was discovered during survey. An interview with the SSD on 10/23/15 revealed she had gone to the hospital and observed the resident prior to her readmission. The resident had not exhibited behaviors when she was observed in the hospital. She said the hospital had added Neurontin to the resident's drug regimen and the first couple of days, the resident was back she still appeared sedated; however, she then started getting back into the behaviors. -The SSD stated she was not aware of the resident being on a one to one (see 10/20/15 readmission note above) and when she had interviewed the resident identified in the incident report with the cane, she stated the resident had not been hit. -She stated staff would talk to her if they needed to put a resident on a one to one, but if they were having concerns with a resident's behavior when she was not there, they could put the concerns on a concern form and she would then figure out a plan of action. Review of the facility's CF AST form (facility guidelines for admission of residents with a history of wandering or elopement, or aggressive behaviors - see abatement plan above) revealed in Section II, that a nursing consult would be needed based on behaviors and medications. -There was no evidence this form had been completed on resident #133's readmission 10/20/15, although it is a part of the facility's readmission process. -Given the resident's history, completion prior to resident #133's readmission would have triggered further screening and an interdisciplinary team discussion about the facility's ability to meet the resident's needs, as well as the safety needs of other facility residents. B. Resident #51 and #76 Interviews and record review revealed residents #51, #76, exhibited physically and verbally aggressive behaviors in the common areas that had the potential to physically harm residents and staff and caused residents to fear for their safety. 1. Allegations of resident to resident and staff abuse involving resident #76 and resident #51 and failure of the facility to protect residents from such abuse. a. Resident #82 Resident #82 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 8/4/15, indicated the resident was cognitively intact, as evidenced by a score of 15 out of 15 on the brief interview for mental status (BIMS) exam. Resident #82 was interviewed on 10/6/15 at 5:50 p.m When asked about concerns or problems with a roommate or any other residents, the resident stated, It's (resident #51). Residents are fearful of him. He can respond in a logical way, but other times he just goes off .He tends to target women. I've seen his handprint on staff . The resident continued, A few months back he wanted to go out so I slipped past him and went out the door. I couldn't get back in because he was swinging the mailbox .It was such a frightening moment .I don't have a lock on my door. I don ' t feel safe . The resident verbalized she wrote a long letter on 7/15/15 about this incident and how it made her fearful, made a copy of it, and then put the copy of the letter into the grievance box which was located outside the administrator's office. The resident showed the letter to this surveyor. The resident stated, They never got back to me. b. Resident #101, age 55, admitted into the facility on [DATE]. He readmitted again on 8/29/15 from the hospital. The resident ' s electronic medical record revealed current [DIAGNOSES REDACTED]. The 7/13/15 Minimum Data Set (MDS) assessment showed the resident's cognition was intact with a brief interview for mental status (BIMS) score of 15. Section C (Cognitive Patterns) revealed the resident did not have any behaviors related to inattention, disorganized thinking, or altered level of consciousness. On 10/6/15 at 3:09 p.m., resident #101 was interviewed. He stated there were times in the facility he felt mentally and emotionally distressed. He stated there were two residents in the facility with known unsafe behaviors. The resident stated one resident (#76) routinely threw items in the dining room with residents present when she was upset. He stated when the resident was in a bad mood, residents had to protect themselves because the staff allowed the resident to act out instead of dealing with the resident's behaviors. The resident further shared there was a second resident (#51) who grabbed the fire extinguisher in the main dining room and he witnessed the resident hit people. He stated the resident grabbed a facility mailbox to use as a weapon. The resident stated he reported these events to staff. He also expressed times when he had to intervene between resident altercations when staff was not available or would not interv

Based on observation, interview, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Specifically, the facility failed to ensure that sufficient nursing staff was in place to meet resident needs related to dignity, choices, accommodation of needs, pain management, pressure ulcers, accident prevention, toileting, grooming and hygiene, behavioral health concerns, and positioning. The lack of sufficient nursing staff contributed to negative resident outcomes; residents expressed fear for their safety, severe pain, incontinence, and sense of worthlessness, as well as the development of additional pressure ulcers for one resident. Cross reference F225, F241, F242, F246, F309, F312, F314, F323, F329, and F441 The findings include: 1. Observations, record review, and interviews with residents and staff, from 10/6/15 to 10/23/15, revealed insufficient nursing staff to maintain the quality of care and quality of life expected and necessary for facility residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being Cross-reference F225G - Failure of nursing staff to timely report, thoroughly investigate and take steps to protect residents from abuse, mistreatment, neglect and exploitation (MANE). Failure of the facility to timely and thoroughly investigate violations involving MANE and take steps to protect residents from MANE contributed to residents fearing for their safety. Cross-reference F241G - Failure of nursing staff to treat residents in a dignified and respectful manner. This failure contributed to one resident feeling worthless, frustrated, angered, embarrassed and dirty when she sat in a wet incontinence brief. Cross-reference F242D - Failure of nursing staff to honor resident preferences regarding bathing. Cross-reference F246D - Failure of nursing staff to ensure resident access to call lights. Cross-reference F309H - Failure of nursing staff to effectively address residents' pain, behaviors, positioning, as well as a failure to coordinate hospice services. These failures contributed to residents fearful for their safety due to, at times, aggressive and violent resident behaviors, residents experiencing severe pain, and one resident developing additional pressure ulcers. Cross-reference F312E - Failure of nursing staff to assist dependent residents with activities of daily living (ADLs) including toileting and showers/baths. Cross-reference F314G - Failure of nursing staff to comprehensively assess, monitor and document information on the status of one resident's skin, communicate with the interdisciplinary team (IDT) and re-evaluate planned interventions when the resident's existing ulcer failed to heal and he developed three new ulcers. Cross-reference F323K - Failure of nursing staff to provide an environment as free from accident hazards as possible, including: A failure to provide residents a safe environment from aggressive, unsafe and, at times, violent behaviors by other residents that contributed to residents' fear for their safety; a failure to prevent resident elopement; and a failure to prevent injuries from heating devices and unsafe smoking. Cross-reference F329D - Failure of nursing staff to prevent the administration of unnecessary medications Cross-reference F441F - Failure of nursing staff to maintain an infection control program to prevent the spread of infection. 2. Resident Population The Census and Conditions of Residents provided by the facility on 10/13/15 revealed: -The census was 93 residents. -75 residents required assistance with bathing. -67 residents required assistance with dressing. -80 residents required assistance with transfers. -83 required assistance with toileting. -74 required assistance with eating. -40 residents had a [DIAGNOSES REDACTED]. -57 residents had a psychiatric diagnosis -42 residents had behavioral health needs. -57 residents were occasionally or frequently incontinent of bladder. -36 residents were occasionally or frequently incontinent of bowel. -57 residents were in a chair all or most of the time. 3. Planned and Actual Staffing Patterns a. Nurses A review of the September 2015 nurse schedules for the building revealed: -Five nurses were scheduled during the day shift. -Five nurses were scheduled during the evening shift. -Three nurses were scheduled during the night shift. Review of the actual staffing for September 2015 revealed the facility did not meet planned nurse staffing on 14 days. b. Certified Nurse Aides (CNAs) A review of the September 2015 CNA schedule showed the facility planned: -Nine CNAs during the day shift. -Nine CNAs during the evening shift. -Four CNAs during the night shift. Review of the actual staffing for September 2015 revealed the facility did not meet planned CNA staffing on four days. 4. Resident Interviews Nine residents, identified by the facility and by cognitive assessment as interviewable, stated during interviews that the facility did not provide sufficient nursing staffing to meet residents' care and services needs in a timely manner. Resident interviews, conducted throughout the facility, revealed the following: On 10/6/15 at 2:00 p.m., resident #60 was interviewed, and was asked if the facility had enough staff to ensure residents received the care they needed without having to wait a long time for assistance. The resident stated, They consider hall 5 and 6 one hall. Hall 5 and 6 have three CNAs. The other halls have two CNAs (each). The girls do the best they can .Some of the nurses will answer the lights but some don't. The girls will ask the nurses, but they will say it's not up to me. I hear a lot of stuff - the girls complaining and no one on the other floor are willing to help them. The resident related that she once waited 40 minutes for assistance. I was in extreme pain - spasms in my legs. They said we had to do that and this, but I'm jumping out of my skin because I'm in so much pain. On 10/6/15 at 2:45 p.m., resident #18 said, They need more CNAs on all the shifts. On the night shift there's one CNA for the 600 hall and one on 500. We all have a lot of problems that take time .They run themselves ragged. The resident verbalized she once waited 45 minutes on the commode - after pressing her call light button - for assistance back to her bed. On 10/6/15 at 3:00 p.m., resident #3 reported she often waited a long time for assistance with going to bed. On 10/6/15 at 3:19 p.m., resident # 101 stated, At night there's not enough staff, and if I was to push the call light, it would be 20 to 30 minutes, and they cut down on nursing and aides - four aides and nurses for the whole building. They say they can do that, but we don't even have a RN (registered nurse) on when there should be an RN in this building. Last week we went without an RN. On 10/6/15 at 3:26 p.m., resident #44 verbalized, They're pretty good but have a hard time because they're understaffed. It sucks having to wait for people. I'm totally dependent and have to wait for someone to pee, sometimes a half hour. On 10/6/15 at 3:40 p.m., resident #122 said, I think they need more girls. You can see it in them. The resident reported she sometimes waited 30 minutes for assistance in the afternoon to be changed or to get up. The resident stated, It makes me feel stinky, dirty. They tell me they were busy in another room. On 10/6/15 at 4:00 p.m., resident #26 reported he had experienced wait times of 30 minutes on all shifts. The resident stated, When I need something, I don't like to push the button during shift change. I try to be considerate. On the third shift there's one CNA. I have a Hoyer lift and they have a long time finding help, so I need to make sure I'm in bed by 10 p.m. before shift change. At home I'm a night owl. On 10/6/15 at 4:55 p.m., resident #82 stated, These halls 5 and 6 are the busiest two halls in the facility. The CNAs don't have time to answer the call lights .I've taken a couple of falls. To be safe I ask for assistance to use the commode. The resident verbalized that one time she had waited 45 minutes for assistance after pressing her call button. On 10/6/15 at 5:00 p.m., resident #28 verbalized that during the evening meal service, No one is here to answer, and I have to catch one going by and yell enough for someone to hear .I train my body to go to the bathroom at prime times when I know someone is around to help me. Last night I waited over two hours for prn (as needed) and break-through (medications) .The button was pressed and they said they would tell the nurse and no one came. On 10/7/15 at 1:00 p.m., resident # 27, who was the resident council president, reported that call light wait times were often brought up by participants of the monthly resident council meetings. The resident stated, They say they're not answering my call light as quickly as they should .A lot of residents have concerns about call lights. 5. Staff Interviews 1. Activities Manager (AM) On 10/7/15 at 1:20 p.m., the AM reported that she had attended the August and September 2015 resident council meetings. The AM shared that at one of the meetings, residents expressed that they were waiting longer for assistance on halls 5 and 6, especially on the weekends when there was just one CNA. The residents were encouraged by other staff members at the meeting to write a statement about this concern. 2. Director of Nursing (DON) On 10/7/15 at 3:20 p.m., an interview with the DON revealed: -Currently (on 10/7/15) the census was 95 residents. -On Hall 2 there were 24 stable long term care residents. Two residents required Hoyer lifts, requiring two staff members for each transfer. -On Hall 3 there were 18 residents with behaviors. Four residents required Hoyer lifts. -On Hall 4 there were 19 younger residents with some behaviors. Two residents required Hoyer lifts. -On Hall 5 there were 19 long term care and overflow rehab residents. Four residents required Hoyer lifts. -On Hall 6 there were 15 rehab residents. Two residents required Hoyer lifts. -The night shift nurse aide (CNA #11), who was scheduled to work on halls 5 and 6, had a caseload of 25 residents. 3. Nurse Aide (CNA #11) On 10/8/15 at 3:30 p.m., CNA #11 verbalized the following: -They (residents) don't like it because it's short-staffed. -I try my best. I have to rush. The other CNAs can't do their (scheduled) rooms here (halls 5 and 6). I say I'll be here as soon as I can. -Last night there were three people screaming on 500. They need someone to stay with them. I can't, so I just keep an eye. The screaming keeps others up. -Skilled (residents) need help to go to the bathroom. -The Hoyer needs two people. 4. On 10/8/15 at 1:06 p.m., an interview with a staff member requesting anonymity for fear of reprisal revealed that s/he was caring for 34 residents. The staff member stated s/he was unable to meet each resident's needs when caring for so many. The staff member stated s/he felt overwhelmed. The staff member stated that s/he would not care for his/her family member in this way. 5. On 10/8/15 at 11:10 a.m., an interview with registered nurse (RN) #4 revealed that she had worked up to 16 days in a row without time off. The RN stated that she was called into to provide coverage as an aide for part of the day shift because they were short today. The RN stated that sometimes she felt burnt-out from working so much and felt like she could not give the care she wanted to. 6. On 10/9/15 at 3:52 p.m. and on 10/13/15 at 4:02 p.m., the DON was interviewed. -The DON revealed that working at the building had been difficult due staffing concerns. She said she had started at the facility on 8/27/15. She said she was having a difficult time keeping up with the demands of the job. -The DON reported that some nursing staff were overworked and were trying their best to keep things together, while other staff needed education. The DON stated there were also staff that needed to be removed, but she could not do that at this time. -The DON stated she did not have an assistant DON (ADON), staff development coordinator, unit manager or any other nurse leader to help her address concerns. The DON stated a new ADON was hired but had not started. 7. Nursing Home Administrator (NHA) On 10/9/15 at 8:35 a.m., an interview with the NHA revealed: -Nights has always been four CNAs. -We're working on getting a unit manager. We had that position but we lost her in July. -The former unit manager was sometimes pulled to the floor. -Unit managers are able to teach and train and observe staff and lay eyes on wounds. 8. Day-Shift Nurse (RN #3) On 10/13/15 at 12:25 p.m., RN#3 stated, We all feel overwhelmed because there's an issue with nursing shortage. It's helpful when there's five nurses, but there's not, so we have to pick up the slack .I hear the CNAs talk all the time about how there should be two on each hall, especially on (halls) 5 and 6 .Residents say the same thing. They say they need more help.

Based on observations, interviews and record review, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically: The resources of the facility were not effectively and efficiently utilized as evidenced by findings that revealed in part: -The facility failed to protect residents from resident to resident abuse. -The facility failed to treat residents with dignity and respect, failed to protect their rights, failed to honor their preferences, and failed to accommodate their needs. -The facility failed to manage residents' pain. -The facility failed to comprehensively assess, monitor, and address resident behaviors, as well as monitoring the effectiveness and necessity of psychopharmacological medications. -The facility failed provide sufficient and qualified nursing staff to ensure residents received the care and services necessary to meet their needs; -The facility failed provide a an environment that was as free from accident hazards as possible. -The facility failed to develop and implement a Quality Assurance program to identify quality deficiencies and to develop effective action plans to address them. Cross-reference F159, F225, F241, F242, F246, F248, F250, F253, F272, F279, F280, F 281, F309, F312, F314, F323, F329, F334, F353, F371, F441, F505, F514, F517, and F520. The findings included: I. Resident Rights Cross reference F159: The facility failed to protect resident funds by notifying residents who were Medicaid participants that their personal funds were approaching the resource limit. II. Resident Behavior and Facility Practice Cross reference F225: The facility failed protect residents from abuse, mistreatment, neglect and exploitation (MANE) by not thoroughly investigating allegations/incidents of potential MANE and taking steps to protect residents during the investigations. This contributed to residents continuing to be fearful for their safety. III. Quality of Life Cross reference F241: The facility failed to treat residents with dignity and respect. This contributed to a resident feeling worthless, angry and frustrated. Cross reference F242: The facility failed to seek and honor resident preferences regarding their life in the facility. Cross reference F246: The facility failed to provide reasonable accommodation of individual resident needs. Cross reference F248: The facility failed to provide individualized activity program to promote a resident's physical, mental and psychosocial well-being. Cross reference F250: The facility failed to provide medically-related social services. Cross reference F253: The facility failed to provide a sanitary, orderly and comfortable environment. IV. Resident Assessment Cross reference F272: The facility failed to complete comprehensive assessments. Cross reference F279: The facility failed to develop comprehensive plan of care. Cross reference F280: The facility failed to review and revise plans of care. Cross reference F281: The facility failed to ensure professional standards of nursing care were followed. V. Quality of Care Cross reference F309: The facility failed to provide care and services to ensure residents' attained and maintained their highest practicable level of physical, mental and psychosocial well-being. Facility failures contributed to residents experiencing severe pain, exhibiting aggressive behaviors that frightened residents, and for one resident whose positioning needs were not addressed, the development of additional pressure ulcers. Cross reference F312: The facility failed to provide assistance to dependent residents with activities of daily living. Cross reference F314: The facility failed to provide treatment and services to prevent and heal pressure ulcers. A resident who entered with one pressure ulcer developed three additional pressure ulcers after admission. Cross reference F323: The facility failed to provide an environment as free from accident hazards as possible. The facility failed to protect residents from abusive resident behaviors which contributed to residents fearing for their safety. The facility further failed to address other accident hazards presented by elopement, smoking, equipment, and unsecured medication carts. Cross reference F329: The facility failed to ensure resident medications regimens were free from unnecessary drugs. Cross reference F334: The facility failed to ensure immunization was discussed/offered to one resident VI. Nursing Services Cross reference F353: The facility failed to provide sufficient nursing staff to meet resident care needs as evidenced by findings that showed residents' need for care and services, as well as their need for safety, were not being met. VII. Dietary Services Cross reference F371: The facility failed to store and serve food in a sanitary manner. VIII. Infection Control Cross reference F441: The facility failed to follow infection control procedures. IX. In addition to the above, the facility failed to ensure the following administrative issues were met: Cross reference F505: The facility failed to ensure laboratory results were promptly reported to the physician. Cross reference F514: The facility failed to ensure clinical records were accurate and complete. Cross reference F517: The facility failed to maintain written, up to date plans and procedures to meet emergencies. Cross reference F520: The facility failed to provide an effective quality assurance system. In summary, over 25 deficiencies were cited during the recertification/ extended survey in multiple regulatory categories affecting resident health, safety and life. One deficiency included findings that placed residents in immediately jeopardy for serious harm (F323K). Two deficiencies included findings of actual harm at a pattern (F309H and F353H). X. Interviews On 10/6/15 an interview with resident #60 revealed that she brought concerns about staffing and other issues to the administration. According to the resident the facility response was to listen. On 10/7/15 at 5:45 p.m., an interview with a member of staff requesting anonymity revealed that s/he has reported concerns to building administration. According to the staff member the administration did not respond to the concerns. On 10/7/15 (time was not noted) an interview with consultant #2 revealed the building's previous administration had caused many of the building's effective staff to leave. By the time the previous administrator was removed, many department heads and other staff had departed. The consultant stated the facility was now in a rebuilding phase because many systems had been lost. On 10/8/15 at 2:32 p.m., an interview with three staff, who requested anonymity, revealed that the facility regularly operated without sufficient staff. The staff felt the administration had not been working to address this problem. According to the staff, they did not have a unit manager or an assistant director of nursing to help with administrative duties and care coordination. On 10/9/15 at 11:09 a.m., an interview with the health information manager (HIM) revealed that she felt the facility did not have effective administration. The HIM stated the previous NHA had been ineffective and had cut so much from staff and services that every other department head and many good staff had left. The HIM stated that she worked to come to meetings with solutions, but that often her suggestions were not considered or implemented. On 10/13/15 at 2:07 p.m., an interview with a staff member requesting anonymity revealed that the administration had done nothing to address staff turnover, which was a major problem for the building. According to the staff member, many competent staff had departed due to the difficult administration. The staff member stated that there was no one in nursing leadership except the Director of Nursing, who was overwhelmed most of the time, to in helping to meet the resident's nursing needs. See F353 for additional resident interviews and F520 for additional administration interviews.

Based on observation, record review, the facility failed to ensure six of 47 sample residents (#44, #3, #56, #133, #51, #26) received the necessary care and services to attain their highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically: -Resident #44: The facility failed to effectively address ongoing pain. Orders and care planned interventions pertaining to the resident's pain were not followed. The facility did not evaluate the effectiveness of the resident's pain medications and interventions either following the administration of pain or during interdisciplinary care conferences. The facility's failures contributed to the resident frequently experiencing severe, unrelieved pain. -Resident #3: The facility failed timely address, through pharmacological and non-pharmacological interventions, the resident's pain which exceeded her acceptable level of pain. Cross reference F241; dignity -Resident #133: The facility failed to adequately assess and address the resident's behaviors of wandering into residents' rooms. The resident's behaviors made residents fearful for their safety. Cross reference F323; accident hazards/resident to resident abuse. -Resident #51: The facility failed to provide necessary care and services to understand and address the resident's aggressive and sometimes violent behaviors that made residents fearful for their safety. Cross reference F225; facility practices and F323; accident hazards/resident to resident and staff abuse. -Resident #26: The facility failed to assess, care plan, and implement pressure relieving strategies to address positioning for the resident who developed three new pressure ulcers after admission. Cross reference F314; pressure ulcers -Resident #56: The facility failed to coordinate with hospice regarding the resident's care needs. The findings include: I. Pain A. Facility Policies 1. Pain Management The facility's Pain Management policy, dated August 2012, read in pertinent part: -Residents will be screened for pain by using the Monthly Summary and the Pain Evaluation Form quarterly, annually, and with a significant change and/or new onset of pain. -Pain intensity and pain relief will be evaluated and re-evaluated at regular intervals. These evaluations will be used by the IDT (interdisciplinary team) to decide the appropriate therapeutic intervention, which may include pharmacological and non-pharmacological techniques. -Additionally, any resident report of inadequate pain control or identified with a new onset of pain, displays new signs or symptoms of pain or identified through the RAI (resident assessment instrument) process will have a full evaluation of the pain conducted using the Pain Evaluation Form. -Following the pain evaluation notify the physician of the findings and document on the Change of Condition / SBAR form. Implement new orders as received. -Each resident identified for pain will have a Pain Management Care Plan. The Care Plan will have individualized interventions related to that resident's individual control of pain management. The Care Plan should include both pharmacological and non-pharmacological pain management interventions. -The pain Management Care Plan with interventions will be updated as indicated and discussed at the IDT stand up meetings, as needed. -The staff will implement the Care Plan, monitor the resident, and administer therapeutic interventions for pain, if ordered. -At any time through the process of Pain Management, the IDT may conduct an At-Risk Review Meeting on the resident, in conjunction with other Risk areas reviewed. IDT referral to Rehab as needed. -If areas for improvement are identified, the Pain Management Program will be reviewed and discussed at the monthly Quality Assurance & Performance Improvement meeting. 2. Care Planning and Care Conference The facility's Care Planning and Care Conference policy, dated January 2012, included the following protocols: -It is vital that care plans address and include the resident's voice, and that evidence is present of his or her involvement in the development and ongoing processes. -The comprehensive MDS (minimum data set) assessment is completed using an interdiscliplinary approach and includes significant input from the resident. Information from the resident regarding his or her needs, desires, and preferences will be a vital part of the care plan development process- from initiation and provision of care to discharge planning. -Care plan review, conduct revisions and updates: as necessary to reflect changes in care and treatment; quarterly; with all comprehensive assessments; and based on resident changes in resident preferences or desires. -Evaluation should include, at minimum: Progress toward goal achievement on or before the target date. Document at minimum in the Progress Notes of the associated discipline; signatures of the participants in the care planning process. Enter on the Care Conference signature sheets. -IDT members are responsible to come to the meeting prepared to discuss resident progress, based on the quarterly progress notes and review of the current care plan problems, goals, and interventions. The IDT signs the Care Conference Attendance Record to validate attendance and files it in the Medical Record under the care plan tab. B. Resident Failures 1. Resident #44 a. Resident Status Resident #44 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly minimum data set assessment, dated 9/14/15, indicated the resident was cognitively intact, as evidenced by a score of 12 out of 15 on the brief interview for mental status exam. The resident required extensive assistance for all activities of daily living. b. Pertinent Physician Orders The October 2015 Order Summary Report included the following physician orders: -(8/24/15) [MEDICATION NAME] Tablet 10-325 mg. Give 1 tablet by mouth every 4 hours as needed for pain. Hold if sedated. -(8/25/15) [MEDICATION NAME] Tablet 10-325 mg. Give 2 tablets by mouth every 4 hours as needed for pain - severe 6-10 pain. -(3/23/15) [MEDICATION NAME] Tablet 600 mg. Give 1 tablet by mouth every 8 hours as needed for pain. -(3/23/15) [MEDICATION NAME] Tablet 1 mg. Give 1 tablet by mouth every 8 hours as needed for anxiety. -(3/23/15) [MEDICATION NAME] Capsule 15 mg. Give 1 capsule by mouth every 24 hours as needed for [MEDICAL CONDITION]. -(9/23/15) [MEDICATION NAME] Tablet 10 mg. Give 1 tablet by mouth one time a day for Depression until 10/8/15. Increase to 20 mg after two weeks. -(10/9/15) [MEDICATION NAME] Tablet 20 mg. Give 1 tablet by mouth one time a day for Depression. -(5/5/15) Pain assessment each shift. -(7/15/15) Therapy to place hot and cold packs as needed for muscle spasms. -(8/26/15) Get soft cervical collar. Wear during the day. -(9/23/15) A telephone order read, Refer pt to pain clinic. c. Care Plans Record review revealed the resident was care planned for alteration in musculoskeletal status, pain and pain medication. (1) Alteration in Musculoskeletal Status, last revised on 4/11/15, read, in pertinent part: -Focus: Resident has an alteration in musculoskeletal status r/t (related to) progression of disease process. -Goal: Resident will have reduced pain or at a level of discomfort acceptable to him through the review date . -Interventions: .Give [MEDICATION NAME] as ordered by the physician. Observe and document for side effects and effectiveness; Heat/cold applications as ordered and as tolerated . (2) Pain The resident's Pain care plan, last revised on 4/11/15, read, in pertinent part: -Focus: Resident has chronic pain r/t his progression of disease process. -Goal: Resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. -Interventions: .Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; .Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition; .Notify physician if interventions are unsuccessful .; Provide non-pharmacological interventions: hot/cold pack application, positioning/support, assistive devices/braces, exercise program, stretching exercises, massage, recreational therapy, activity programming, music, aromatherapy, meditation; Therapy referral as indicated. (3) Pain Medication The resident's Pain Medication care plan, last revised on 4/11/15, read as follows: -Focus: Resident receives pain medication therapy r/t chronic pain. -Goal: Resident will have reduced pain by next review date with current interventions in place. -Interventions: Administer [MEDICATION NAME] medications as ordered by physician; observe/document side effects and effectiveness q(every) shift; Ask physician to review medication if side effects persist. Notify physician for any unrelieved pain . d. Medication and Treatment Administration Records Review of medication and treatment records revealed the resident experienced severe pain at times and frequently received PRN pain medication. Nonpharmacological interventions ordered (heat/cold packs, soft cervical collar) were not implemented to compliment medication management of the resident's pain. (1) September 2015 The September treatment administration record (TAR) indicated the following: -On the day shift, the resident's pain level was severe (6 - 10) on 13 out of 30 days. -On the evening shift, the resident's pain level was severe (6 - 10) on 18 out of 30 days. -The resident did not receive the following order on any day in September: Therapy to place hot and cold packs as needed every 2 hours for muscle spasms. -The order to wear a soft cervical collar during the day (8/24/15) was not indicated on the TAR. The September Medication Administration Record [REDACTED] -On the day shift, the resident received two PRN [MEDICATION NAME] tablets on 29 out of 30 days, and an additional one PRN [MEDICATION NAME] tablet on seven out of 30 days. The effectiveness of the medication was not documented. -On the evening shift, the resident received two PRN [MEDICATION NAME] tablets on 17 out of 30 days, and an additional PRN [MEDICATION NAME] on seven out of 30 days. The effectiveness of the medication was not documented. (2) October 2015 The October TAR (10/1/15 through 10/9/15) indicated the following: -On the day shift, the resident's pain level was severe (6-9) on 2 out of 9 days. -On the evening shift, the resident's pain level was severe (6-9) on 5 out of 9 days. -The resident did not receive the following order on any day in October: Therapy to place hot and cold packs as needed every 2 hours for muscle spasms. -The order to wear a soft cervical collar during the day (8/24/15) was not indicated on the TAR. The October MAR (10/1/15 through 10/9/15) indicated the following: -On the day shift, the resident received two PRN [MEDICATION NAME] tablets on 8 out of 9 days. The effectiveness of the medication was not documented. -On the evening shift, the resident received two PRN [MEDICATION NAME] tablets on 8 out of 9 days. The effectiveness of the medication was not documented. e. Care Conferences Review of the resident's record showed there one care conference since admission, which occurred on 6/30/15. The Care Conference Note, dated 7/3/15, read, IDT met for residents quarterly C.C. (care conference) on 6/30/15. Resident was invited but declined at this time. Resident is on mechanical soft and is at 95% intake. Resident weight is 154. Resident often stays in his room. Resident has recently been moved to different room and resident reports he has no issues with room change at this time. Resident's placement plan is for LTC (long term care). The note did not indicate which staff members participated in the care conference. There was no indication an attempt was made to reschedule the care conference to accommodate the resident's scheduling preference. There was no evidence the resident's pain was discussed among IDT members and with the resident, or that interventions were reviewed. The resident's care plans were not updated. f. Nurses' Notes The resident's record included the following Nurses' Notes, from 9/29/15 through 10/9/15, documenting the resident was experiencing unrelieved, severe pain almost daily. Specifically: -(9/29/15, 6:31 a.m.)-Pt (patient) complains of different type of pain - severe burning along back. Admin 2 narco po (by mouth). -(9/29/15, 12:00 p.m.)- c/o (complains of) neck and shoulder pain 9/10. -(9/30/15, 5:18 a.m.)- Pt complains of sharp pain in back up neck 10/10 request pain med admin 2 narco 10/315 will continue to monitor -(9/30/15, 10:48 a.m.)- c/o pain neck and shoulder 9/10 -(9/30/15, 9:23 p.m.)- Resident states I'm still in a lot of pain. -(10/1/15, 4:42 a.m.) - Pt complains of burning type pain shoulder, back and neck admin 2 narco . -(10/1/15, 10:52 a.m.)- c/o neck and shoulder pain 9/10 -(10/2/15, 5:22 a.m.)- Pt complains of sharp burning pain down back and across shoulders and neck. admin 2 narco . -(10/4/15, 4:45 a.m.) - Resident states pain to neck and back -(10/6/15, 6:05 a.m.)- Pt complains of sharp pain neck shoulders and back admin 2 narco . -(10/6/15, 7:15 a.m.) - For the past several weeks it seems pt pain has changed in intensity pt says it is sharp stabbing often radiating from skull to spine pt says he does get some relief with meds . -(10/7/15, 6:35 a.m.)- Pt complains of pain 9/10 sharp neck shoulders back shooting down spine . -(10/7/15, 1:35 p.m.)- c/o neck and shoulder pain 8/10 -(10/8/15, 11:06 a.m.)- c/o neck and shoulder pain 8/10 -(10/9/15, 5:14 a.m.) - Resident asked for [MEDICATION NAME], for pain 9/10 neck and shoulder pain The nurse's notes 9/29/15 - 10/9/15 did not document any calls to the physician or nurse practitioner regarding the resident's high pain levels or the frequent administration of PRN medication for pain. Moreover, there was no reference in the notes regarding the 9/23/15 referral to the pain clinic. g. Physician Notes The record contained a physician progress notes [REDACTED]. A telephone order, dated 8/24/15, read, Increase to 10mg/325mg one to two every 4 hours as needed, Hold if sedated. The record did not contain a subsequent physician note. h. Interviews (1) Resident a) 10/6/15 On 10/6/15 at 3:30 p.m., the resident was asked about the presence of pain currently or recently that was not relieved. The resident responded, I'm always in pain .I think they need to give me something different .I just keep telling them about the neck brace from a month ago for ALS and it still hasn't arrived. I've asked the nurses and (restorative aide, certified nurse aide #10). b) 10/9/15 During a conversation with the resident on 10/9/15 at 1:45 p.m., the resident made the following comments: -I have pain all the time. It's bad. It's mostly up in my neck. It comes on hard and it makes me agitated. It's always at a 9 or 10. The medication calms it down but not for long. -I haven't seen the doctor in a long time. -I have pain at night but I try not to take my pain med. If I don't take it at 4 (am), I can't do anything during the day. They don't understand how much pain I'm in. I'm almost crying about it. I don't know why they haven't tried anything else like a patch. I was telling them and telling them and telling them. -PT (physical therapy) rubs my neck for 10 minutes. If I had more of it I think it'd be better. She has too many people. -A care conference would be good to know why I'm in pain. This is crazy. c) 10/13/15 On 10/13/15 at 1:00 p.m., the resident verbalized he received a soft cervical collar on Friday, 10/9/15 (ordered 8/24/15). The resident said, It helps hold my head up when I'm sitting. There's a little bit less pain (with it on). It's better than nothing. The resident further stated that the restorative aide provided him with ice packs several days a week for a couple hours - it helps. The resident added, I'd like a heating pad several times a day. It's ordered, but they're scared I'll get burned .When I don't have those meds I'm in tremendous pain. It gets so bad. That's why they got me on depression meds. (2) Staff a) Director of Nursing During interviews with the director of nursing (DON) on 10/9/15 at 1:15 p.m. and on 10/13/15 at 1:10 p.m., the DON reported that on 8/24/15, the dosage of [MEDICATION NAME] was increased for the resident because the nurse came to me and said he's complaining (the pain medication ordered at that time was) not effectively holding his pain. The DON acknowledged that the effectiveness of this increase had not been evaluated. The DON said, It's been overlooked. There's no weekly pain review .We need to establish his expected level of relief to see what his goal is. We want to see it below 5 .The previous social worker worked with some residents on palliative approaches. The IDT should explore trials of non-pharmacological interventions. b) Scheduler/Unit Assistant (UA) On 10/9/15 at 2:55 p.m., the UA was asked about the telephone order, dated 9/23/15, to refer pt to pain clinic. The UA verbalized she was responsible for scheduling appointments. The UA acknowledged a copy of this telephone order was placed on her desk, but she had not yet scheduled the appointment. The UA confirmed she did not ask another staff member to follow up on the order. c) Nurse (RN #3) On 10/13/15 at 10:25 a.m., a day-shift nurse (RN #3) verbalized she wrote the telephone order to refer the resident to the pain clinic on 9/23/15 for another nurse (LPN #2) who was concerned about the resident's ongoing pain. RN #3 indicated she was not aware that this order had not been followed up on. RN #3 said, Orders should be called in either that day or the next day at the latest. I gave it to (UA), made a copy, and gave it to (LPN #2). The nurse should follow up if (UA) couldn't do it. d) Nurse (LPN #2) On 10/13/15 at 10:40 a.m., LPN #2 reported the following: -The resident complains of neck and shoulder pain a lot. He's been taking (pain medication) every four hours. I've talked with his NP (nurse practitioner) several times, and she's not going to increase it. LPN #2 confirmed that her discussions with the NP about the resident's pain were not documented. -The NP ordered the referral to the pain clinic on 9/23/15. The LPN said, I asked (UA) last week about this order, and the UA said, I'm getting to it. -The first time she observed the resident wearing a collar was on Saturday, 10/10/15. Therapy is supposed to order the collar because it's supposed to be measured. -The nurse confirmed the 7/15/15 order for Therapy to place hot and cold packs as needed for muscle spasms was not carried out by either Therapy or Nursing. -The nurse did not know the reason [MEDICATION NAME] was being prescribed as a PRN medication, when it was given to the resident routinely on a daily basis. e) Director of Rehabilitation Services (DOR) On 10/13/15 at 11:00 a.m., the DOR, who started working in the facility in September, verbalized that Nursing asked Therapy to order the cervical collar in August. The DOR stated, I noticed it wasn't ordered when I came in, so I ordered it because (the resident) asked me about it .It's normally ordered by Nursing. Nursing can do the hot pack and cold pack. The DOR said the (7/15/15) order should have been written without stating that Therapy was to place the hot and cold packs The DOR further indicated that the involvement of residents and IDT members in quarterly care conference was important in identifying concerns such as ongoing pain and reviewing the effectiveness of interventions. The DOR said, We can ask, What is your pain level? The DOR confirmed the resident was not currently receiving therapy services. f) Restorative Aide On 10/13/15 at 11:10 a.m., the restorative aide (CNA #10) verbalized she gave the resident a shoulder massage for approximately 10 minutes, along with a heating pad, during his 30 minute session in the therapy room five to six mornings a week. CNA #10 stated, He tells me in the evening his shoulders are in pain. Some days he has more pain than others. He says, Tell them I need more pain medication, even after therapy. i. Facility Failures The facility failed to ensure resident #44 received the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being. The facility did not effectively address the resident's ongoing pain, as outlined below: -The resident's pain intensity and pain relief were not evaluated at regular intervals, per facility policy. -The care plans related to pain had not been updated since admission with revised interventions as the resident continued to report severe levels of pain. -The interdisciplinary team did not review the resident's pain management interventions to assess the effectiveness of ordered and planned interventions. -There was no evidence that the resident's pain was discussed at the only care conference conducted in after the resident's admission. There was no evidence the resident was involved in the development and ongoing processes of care planning. There were no Care Conference signature sheets. -The 7/15/15 order Therapy to place hot and cold packs as needed for muscle spasms was not carried out. -The 8/26/15 order Get soft cervical collar. Wear during the day was not implemented until 10/9/15 during the survey. -The anti-depressant [MEDICATION NAME] was added to the resident's medication regimen on 9/23/15. The resident indicated on 10/13/15 at 1:00 that [MEDICATION NAME] was initiated for him in part because of his depression related to experiencing persistent pain. -On 9/23/15, a telephone order Refer pt to pain clinic was written. This order was not carried out. -The resident's record did not contain evidence the physician was notified about a change in pain intensity, as indicated in the 10/6/15. 7:15 a.m. nurses' note: For the past several weeks it seems pt pain has changed in intensity pt says it is sharp stabbing often radiating from skull to spine pt says he does get some relief with meds . 2. Resident #3 (Cross reference F241; dignity) a. Record review Resident #3, [AGE] years old, admitted to the facility on [DATE] with the following diagnoses, according to the face sheet: diabetes mellitus type II, chronic pai[DIAGNOSES REDACTED], restless leg syndrome, overactive bladder, dyspnea, history of urinary tract infections (UTIs), and migraines. On 8/12/15 the admission minimum data set (MDS) documented the resident's brief interview for mental status (BIMS) score was 12 out of 15, which indicated that her cognitive status was moderately impaired. She required extensive assistance of one to two persons with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. The resident received scheduled and as needed (PRN) pain medications. She received non-medication interventions for pain. She had almost constant pain symptoms. She rated her pain level at eight out of ten with ten being the worst pain level. On 8/22/15 (last revised) the pain care plan documented that the resident had chronic pain related to her [DIAGNOSES REDACTED]. She received scheduled and PRN pain medication. The interventions included: - Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions 30 min (minutes) after administration. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Hospice consults as indicated. -Observe/document for probable cause of each pain episode. Remove/limit causes where possible. -Observe/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. -Provide non-pharmacological interventions: hot/cold pack application, positioning/support, assistive devices/braces, exercise program, stretching exercises, massage, recreational therapy, activity programming, music, behavior management, aromatherapy, chaplain/religious support if requested, counseling/support via psychology, social services. -Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to s/sx (signs and symptoms) or c/o (complaint of) pain or discomfort. Therapy referral as indicated. On 8/10/15 the pain evaluation form documented that the resident had chronic pain from a prior back surgery and arthritic shoulders. She experienced arthritic and [MEDICAL CONDITION] pain. She described it as a sharp ache. She rated her pain level at eight out of ten. The worst pain level was ten out of ten and the best level was six out of ten. The goal was to get her pain level to where it hurt a little bit/mild pain. She was not satisfied with current level of pain control and wanted an alternative to pain medications. Nothing else was documented regarding this request for alternative treatments. Rest, ice/cold pack, and medication therapy was effective for pain control. She reported that her pain was worst in the morning upon waking. She was able to verbalize pain. She reported that the pain interfered with sleep and physical activity. On 10/15 the medication administration records (MARs) and treatment administration records (TARs) documented the following orders, in pertinent part: - Order date: 8/5/15: [MEDICATION NAME] 1500 milligrams (mg) by mouth (p.o.) at bedtime for joint pain. - Order date: 8/5/15: [MEDICATION NAME] Chloride extended release (ER) 10 mg p.o. daily for bladder spasms. - Order date: 8/5/15: Requip 3 mg p.o. at bedtime for RLS. - Order date: 8/5/15: Tylenol extra strength (ES) 1,000 mg p.o. at bedtime for pain. - Order date: 8/5/15: [MEDICATION NAME] 300 mg p.o. twice a day for [MEDICAL CONDITION] pain. - Order date: 8/5/15: [MEDICATION NAME] 600 mg p.o. twice a day for [MEDICAL CONDITION] pain. - Order date: 8/5/15: Apply cold compress for comfort as needed (PRN) every four hours for [MEDICAL CONDITION]. - Order date: 8/5/15: [MEDICATION NAME] Migraine 250/250/65 mg give one tablet (tab) p.o. every six hrs PRN for migraines. - Order date: 8/5/15: [MEDICATION NAME] 5/325 mg give one tab p.o. every four hours PRN for pain. - Order date: 9/8/15: Tylenol 650 mg p.o. every four hours PRN for pain may take with [MEDICATION NAME]. - Order date: 8/6/15: Observe for pain every shift. If pain present, complete pain flow sheet and treat trying non-pharmacologic interventions prior to medicating, if appropriate. Document in the progress notes (PNs). b. Resident interview On 10/6/15 at 2:53 p.m. the resident reported that the interview might be interrupted by the Certified Nursing Aides (CNAs) because she had told them at 11:00 a.m. that she needed to use the bathroom. She was observed rubbing her legs. She reported that the longer she waited to be transferred to bed so she could use the bedpan, the more her legs would hurt her. She said she had to wait for a long time for the staff to assist her to the toilet. She reported that sometimes her legs would hurt so bad that she could not assist the staff with her bed mobility. She reported that she told the staff all the time how bad she hurt when they made her wait but they did not do anything about it. At 3:44 p.m. the staff had not yet responded to the resident's request to use the bathroom The resident turned on the call light at 3:44 p.m. so she could request to use the bathroom again. She repeated that she had been waiting for assistance since 11:00 a.m. and how bad she was hurting as she continued to rub her legs. She reported that her pain level currently was eight out of ten. She reported that most days she had no problem with her pain level but on the days like today when she had to wait a long time to be given assistance with her transfers, her pain level would jump to ten out of ten. She reported that her pain level was comfortable for her at five out of ten. She reported that it was difficult to get her pain level under control once she had reached that level of pain. She reported that when she experienced pain she would notify the CNAs and they would tell the nurse. She reported that most of the time when she told the CNAs about her pain the nurse would not give her anything, so she would have to hunt down the nurse to give her the pain medications. She did not think the CNAs were good at telling the nurse that she was in pain. c. Observations (1) 10/6/15 On 10/6/15 at 3:54 p.m. CNA #16 responded to the resident's call light. The resident told the CNA she had needed to go to the bathroom since 11:00 a.m. and she was hurting. The CNA did not respond to the resident ' s statement. At 3:59 p.m. CNA#16 went to find CNA #13 to assist with the cares and transfer. At 4:01 p.m. CNA #16 returned to the room with the Hoyer lift. At 4:04 p.m. the resident asked CNA #16 to go and find the other CNA. CNA #16 left the room. At 4:06 p.m. both CNAs returned to the resident's room. They began transferring the resident to her bed using the Hoyer lift. At 4:07 p.m. the resident was not able to hold herself up on the bed during the insertion of the bedpan. She reported it was because she had stayed up in the wheelchair for too long and was weak and in pain. The CNAs continued cares with the resident without responding to the resident's statements about pain and weakness. At 4:17 p.m. to 4:23 p.m. the CNAs stood in the hallway waiting for the resident to use the bedpan in private. At 4:36 p.m. the CNAs transferred the resident from the bed to the wheelchair using the Hoyer lift. The resident reported that her pain level was at seven out of ten. She said she would ask the nurse on the way to the activity for a pain pill. The CNAs were not observed to notify the nurse of the resident's pain level. (2) 10/7/15 On 10/7/15 at 2:27 p.m. the resident was observed asking CNA #4 for assistance to the bathroom. The CNA told the resident that the next shift was coming on in three minutes to four minutes so they could help her. The CNA reported that she would notify the next shift so they could assist her first. The resident stated to the CNA, This is what I mean. You guys always tell me the next shift will do it and I'm hurting. This is what makes me mad. They don't get it (that) my legs hurt a lot when I have to wait a long time for someone to help me. The CNA did not respond. She did not offer to notify the nurse that the resident had reported she was hurting. At 2:42 p.m. CNA #16 stopped by and spoke to the resident. The resident told her that she had been waiting since the prior shift to go to the bathroom and her legs were hurting. The CNA reported that she would try to get her to the toilet soon. At 2:56 p.m. the resident put her call light on and stated, I don't know if the CNAs understand that I have to go to the bathroom and my legs are killing me? She reported that her pain level was eight out of ten. She said when she saw the CNAs; she would make sure they told the nurse about her pain. At 2:58 p.m. Licensed Practical Nurse (LPN) #5 answered the resident's

Based on record review and interviews, the facility failed to provide evidence all alleged violations involving mistreatment, abuse, neglect and exploitation (MANE) were thoroughly investigated for five (#82, #44, #51, #76, and #133) of nine out of 47 total residents sampled. Specifically, the facility failed to ensure all alleged violations were timely reported, thoroughly investigated and steps were taken to protect residents from further abuse. Record review revealed violations of potential MANE continued per documentation in progress notes. Residents expressed they were fearful for their safety when residents #51 and #76 'acted out,' feared being hit by objects thrown by resident #76 and feared resident #51 and #76 would go after them. Cross-reference F309; quality of care; failure of facility to understand and address resident #51 and resident #133's behaviors. F323; accident hazards; failure of facility to protect residents from resident to resident abuse. The findings include: I. Facility Policies: In pertinent part: The 6/13 Abuse and Neglect Prohibition policy revealed: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property .Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator and/or Director of Nursing. The 6/13 Incident/Accident Reporting for Residents indicated: All incidents, accidents, and unusual occurrences involving a resident are documented and reported. All incidents considered to be or have the potential to be, significant and/or serious are reported timely to the facility Administrator (abuse coordinator) and to Risk Management and in accordance with any federal and state law. The facility thoroughly investigates any such incident. II. Facility failure to thoroughly investigate and protect residents for abuse A. Resident #51 1. Resident #51, age 77, admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. He was transferred to the hospital for a psychiatric evaluation on 7/10/15, but returned to the facility the same day. The 6/8/15 MDS revealed the resident's cognition was severely impaired with a brief interview of mental status (BIMS) score of one out of 15. Section C (Cognitive Status) identified the resident presented with behaviors of inattention and disorganized thinking. Section E (Behaviors) indicated the resident had hallucinations and delusions. The resident's overall presence of behavioral symptoms was not filled out to determine how the resident ' s behaviors impacted the resident or others although behavioral symptoms were present. Section E further showed on a daily basis, the resident had physical and verbal behavioral symptoms directed toward others. The 9/3/15 MDS did not identify any hallucinations or delusions in section E. The assessment did report physical and verbal behavioral symptoms occurred one to three days. The presence of the behavioral symptoms according to the assessment did not impact the resident or put him as risk for physical illness or injury; did not significantly interfere with his care; did not significantly impact others or put others at risk for physical injury; did not disrupt care or living environment. The 3/28/15 behavior care plan, revised on 4/12/15, identified the resident had been verbally and physically aggressive to staff and other residents. The resident displayed poor impulse control and anger. The resident had a history of [REDACTED]. -The goals were the resident would have zero to one episode per day through the next review date. The resident's aggressive behaviors would be minimized with intervention through next review period as evidenced by no harm to self or others. -The interventions listed to address the resident's behaviors were: administer medications as ordered; observe/document for side effects and effectiveness; analyze time of day, places, circumstances, triggers, and what de-escalates behavior and document; assess and address for contributing sensory deficits; assess and anticipate resident needs: food, thirst, toileting, comfort level, body positioning, pain; give resident as many choices as possible about care and activities; observe/document/report as needed any signs or symptoms of resident posing danger to self and others; psychiatric/psychogeriatric consult as indicated; when resident becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk away calmly, and approach later. There were no new interventions listed after 3/29/15 although the resident had ongoing behaviors between 7/10/15 - 9/13/15. 2. Allegations involving MANE toward residents and staff On 10/6/15 at 3:09 p.m., resident #101, who was alert and oriented per his 7/13/15 MDS assessment, was interviewed. He stated there were times in the facility he felt mentally and emotionally distressed. He stated there was an incident when resident #51 grabbed the fire extinguisher in the main dining room to use as a weapon. He said he witnessed the resident hit people. He stated the resident also grabbed a facility mailbox to use as a weapon. On 10/6/15 at 5:50 p.m., resident #82, who was alert and oriented per her 8/4/15 MDS assessment, was asked about concerns or problems with a roommate or any other residents. The resident stated, It's (resident #51). Residents are fearful of him. He can respond in a logical way, but other times he just goes off .He tends to target women. I've seen his handprint on staff . The resident continued, A few months back he wanted to go out so I slipped past him and went out the door. I couldn't get back in because he was swinging the mailbox .It was such a frightening moment .I don't have a lock on my door. I don ' t feel safe . On 10/7/15 at 2:39 p.m. a certified nurse aide (CNA) #18 was interviewed. The CNA confirmed there had been an incident when resident #51 was agitated in the dining room and obtained a fire extinguisher to use as a weapon. The CNA recalled the resident punched a staff member in the chest and resident #51 had to be removed from the dining room. On 10/7/15 at 3:30 p.m., a licensed practical nurse (LPN) #7 was interviewed. The LPN confirmed resident #51 had dementia and was combative at times. She said she had been a victim of resident #51's aggressive behavior. The LPN acknowledged the resident had pulled the pin from a fire extinguisher and had hit a number of people including the LPN in the dining room. The LPN stated a police report was filed. On 10/8/15 at 9:46 a.m., CNA #5 was interviewed. The CNA stated resident #51 has grabbed the fire extinguisher to use as a weapon more than once. The CNA said the resident was combative and he, too, had been a victim of the resident's aggressive behavior. He stated residents have reported to him they feel scared when resident #51 is seen exhibiting such behaviors. The CNA further shared it was not safe for resident #51 to grab hold of fire extinguisher as he could spray himself with contents. The CNA reported he informed the floor nurses when residents reported they were scared or afraid. On 10/8/15 at 10:14 a.m., CNA #20 was interviewed. The CNA said residents have told her they do not feel safe when resident #51 acts out. On 10/8/15 at 1:26 p.m., LPN #2 was interviewed. She reported incident reports (situation/background/assessment/recommendations -SBAR) were completed for aggressive behaviors by residents towards staff and other residents that endangered their safety. The LPN did not identify any other steps that would be taken under such circumstances, such as notifying the director of nursing (DON) or nursing home administrator (NHA) after incident reports were completed in the facility's electronic medical record. The LPN stated she was hit by the resident and a police report was filed. On 10/8/15 at 1:41 p.m., LPN #5 was interviewed. She stated nurses were expected to report to the NHA or DON events such as skin tears, falls, scratches, behaviors, unknown bruises and any kind of elopement; she did not identify that behaviors which endanger residents and staff should be reported. . On 10/8/15 at 4:01 p.m., resident #101 was interviewed again. He stated he felt resident #51 was violent. He stated he felt he and other residents at the facility were in danger when the resident acted out and some residents felt the resident could go after them. The resident stated during the time he was recovering from an accident, he felt resident #51 could have easily hurt him. The resident did not feel the facility had the accommodations to meet the needs of resident. The resident felt the facility did not provide adequate reassurance to residents after violent outbursts observed by residents at the facility. 3. Record Review a. Progress notes A review of resident #51's progress notes 7/10/15 - 9/13/15 revealed: -On 7/10/15, resident #51 threw trays into a crowded dining room, pulled the fire extinguisher off the wall and tried to hit people. -On 7/14/15, resident #51 hit the front glass door with the big black mail box. The notes indicated the resident physically and verbally assaulted a staff member and swung at police officers. - On 7/21/15, an at-risk resident review (ARR) met for discussion of the resident's behaviors of aggression and most recently verbal sexual behavior towards staff. The facility was considering an all male dementia unit and waiting on a response. The resident was going to continue to be followed in weekly ARR. However, there were no ARR notes prior to 7/21/15 to address resident behaviors and there were no ARR notes following the resident after 7/21/15 although inappropriate behaviors continued to be seen. Specifically, progress notes revealed the resident continued to exhibit unsafe, aggressive, and inappropriate behaviors on 7/15/15, 7/18/15, 7/20/15, 7/22/15, 7/23/15, 7/30/15, 8/7/15, 8/12/15, 8/15/15, 9/7/15, 9/8/15, and 9/13/15. (Cross refer to F309; quality of care). (2) Investigation On 10/8/15 at 3:10 p.m., the NHA, consultants (Conslt) #1 and #2, and DON provided the following SBAR and progress notes as evidence of their investigation of the 7/10/15 incident. - The SBAR communication form dated 7/10/15 related to resident #51 read in pertinent part: The SBAR identified a change in the resident's status because he was combative. The things which made the resident's condition worse was trying to stop him from going where he wanted and doing what he wanted to do. The thing which made the resident's condition and symptoms better was an anti-anxiety medication, [MEDICATION NAME]. The SBAR revealed the resident's combative behavior had occurred before and the treatment for [REDACTED]. The SBAR stated the resident had new or worsening behavioral symptoms and the resident was physically aggressive and needed antipsychotic medications and medication management. The report stated the resident was transferred to the hospital for a (psychological) evaluation and further noted the resident was having increasingly frequent episodes of physical aggression. No police reports were provided. -Progress notes from 7/10/15 to 7/11/15. In pertinent part: Resident was being transferred to hospital for uncontrollable violent behavior .he continued to be physically aggressive and had to be pulled from the door way so kitchen staff could lock the kitchen door .the resident started to throw trays and trash can into the crowded dining room. When all throwable objects were removed from his reach, he pulled the fire extinguisher off the wall, and tried to hit people with it, then pulled the pin and was about to discharge it when another staff member came up behind him and was able to pull it from his hands. He continued to physically assault staff while he was being wheeled to his room. Once in his room, he started throwing things (then) charge staff. He chased staff down the hall throwing whatever he could get to. Residents had to be taken to another area for (their) safety. Resident was sent to the hospital for a psychological evaluation. .resident had behavior issue and upon arrival resident was seated in wheelchair swinging clinched fists, and kicking at staff .resident grabbed box of gloves and threw them at the DON (director of nurses) .resident grabbed staff ' s wrist and struck nurse in upper abdomen police arrived as resident entered the common area .resident cursing and attempted to strike officers; officers were able to talk resident down without use of force and resident taken to hospital for psychological work up. 3. Failures in the facility's response to violations involving MANE No investigations were provided for the incidents documented in the progress notes on 7/14/15, 9/4/15 and 9/13/15, see above. There was no further discussion of the resident's behaviors in the ARR although per the 7/21/15 note, the resident was to be discussed weekly (see above). Resident #82 (see above) stated in her interview on 10/6/15, that she wrote a long letter on 7/15/15 about the incident with resident #51 swinging the mailbox and how it made her fearful, made a copy of it, and then put the copy of the letter into the grievance box which was located outside the administrator's office. The resident showed the letter to the surveyor. The resident stated, They never got back to me. Regarding the incident on 7/10/15, the facility failed to provide any witness statements or interviews from residents or staff regarding the incident and their response to the incident. There were no summary findings of an investigation; the facility failed to document actions taken in response to the findings (other than hospitalization ). The SBAR did not discuss the resident ' s environment, predisposing factors, interventions, or attempt to identify root causes. There was no evidence the facility discussed the steps that would be taken to keep residents safe when resident #51's behaviors escalated. On 10/8/15 at 3:10 p.m., the NHA, consultant (Conslt) #2, and DON were interviewed. -The NHA said the facility attempted to hospitalize the resident after the 7/10/15 incident but the mental health hospital was unable to take the resident. The NHA did not indicate any other mental health supports were pursued in an effort to educate staff how to effectively and consistently intervene to address resident #51's behaviors and to keep other residents safe from harm. -The DON confirmed there was no interdisciplinary note (IDN) to show the facility discussed the incident, the resident's behaviors, or a safety plan to protect residents from physical and mental abuse by the resident, after the 7/10/15 incident or after the incidents that followed on 7/14, 9/4, and 9/13/15 (see progress notes above) . -Conslt #2 stated the facility attempted to protect residents and isolate resident #51 as he acted out on 7/10/15.; however, the resident did not have interventions on his behavior care plan updated since 3/29/15. He stated the facility attempted to de-escalate the situation, although specific interventions were not articulated or provided for review. He stated the immediate response of the facility was to send the resident out of the facility but offered no other interventions to ensure residents' ongoing safety from resident #51 aggressive behaviors. On 10/13/15 at 4:00 p.m., a registered nurse (RN) #1 was interviewed. She stated she hasn't been asked to discuss the resident's behaviors and hasn't been given any specific interventions to help de-escalate the resident when inappropriate behaviors are seen. She stated she was unaware of effective interventions determined by the facility's management team to assist the resident. She said because she was unfamiliar with how to intervene in resident behaviors, she was not able to direct CNAs on proper techniques to help the resident and situation. The RN stated she and other floor staff used a 'trial by fire approach' when resident #51 acted out and had to be calmed. The RN stated the facility management team was responsible for identifying problems and approaches but the facility did not have any management to discuss resident issues effectively and consistently. The RN stated there were still a few residents leery of resident #51. B. Resident #44 1. Resident #44, age 52, entered the facility on 3/23/15. The facility face sheet indicated the resident was admitted with [DIAGNOSES REDACTED]. The 9/14/15 Minimum Data Set (MDS) revealed the resident ' s cognition was moderately impaired with a brief interview for mental status (BIMS) score of 12. Section G (Functional Status) indicated the resident had limited range of motion of upper and lower extremities to both sides. On 10/6/2015 at 3:26 p.m., resident #44 was interviewed. He reported that because of his ALS and MS, he was dependent on someone to assist him with all cares. The resident stated he was not able to move his arms or legs; he needed total assistance. He said he had a touch pad call light to alert staff when assistance was needed. 2. Allegation of potential violations involving MANE On 10/08/15 at 4:01 p.m., resident #44 said the other night a female resident (resident #133) with known behaviors entered his room unexpectedly and uninvited while he was in bed, took his call light, wrapped the cord around her neck and almost knocked over his large flat screen television. The resident stated he was scared the resident was going to jump into his bed and he was unable to do anything to help himself. He stated there was another resident who entered his room when he was sleeping at times and would stare at him. He stated it was creepy to see a resident staring at him. On 10/08/15, the resident's roommate, resident #101, who was alert and oriented per 7/13/15 MDS assessment, was interviewed at 4:10 p.m. Resident #101 stated he reported the above incident to the evening nurse (Licensed Practical Nurse #3). He stated the uninvited resident also walked in on him while he was urinating in the restroom and entered another person's room afterward. Resident #101 stated no one has spoken to him about the incident and what he had witnessed involving resident #44. 3. Record Review: A review of the resident #44's progress notes from 10/6/15 through 10/13/15 failed to show any documentation related to the incident involving a female resident entering the resident's room uninvited and the resident feeling scared the female resident would jump in bed with him. 4. Staff Interviews - failure to promptly report allegation On 10/8/15 at approximately 4:20 p.m., conslt #1 and conslt #2 were informed of the incident reported by resident #44 and #101. Conslt #1 stated she was not aware of the incident and would follow-up. Documentation regarding the incident was requested. On 10/8/15 at approximately 4:45 p.m., conslt #3 stated she was not aware of an incident involving the uninvited resident and resident #44. Conslt #3 stated the resident's degree of ALS prevented him from moving his extremities. She stated she would look into an intervention allowing the resident to feel safe and protected from individuals entering his room. d. Facility Follow-up On 10/9/15 at 3:45 p.m., conslt #1 provided a copy of a incident/accident report dated 10/6/15. The conslt reported the incident report was a late entry and was actually completed on 10/9/15 although the event occurred on 10/6/15. The conslt stated the investigation did not take place until 10/8/15 after the facility became aware of the incident. The facility provided an investigation completed 10/9/15 which consisted of the following: -Incident/Accident Report (late entry completed 10/9/15) The findings section revealed, (A) female resident was found in (resident #44's) room (with) his call light draped around her shoulders and neck. Resident stated, (She) scared me. I thought she was gonna jump in bed (with) me. -Interview of LPN #3 dated 10/8/15. In pertinent part, .The male resident reported that she scared me because I thought she was going to jump into bed with me. The nurse did not interpret the resident's statement as being fearful but rather more along the lines of being concerned . -Interview of resident dated 10/8/15 completed by social services director (SSD). As it pertains, he was more startled to see them in his room. He wished staff would get (the uninvited residents) under control. -Questionnaire completed with resident #44. In review of the questionnaire, the resident expressed he was nervous he couldn't defend himself the other night when a resident entered his room and he did not have access to his call light. 4. Failures in facility investigation The facility did not summarize their findings, did not indicate how they planned to keep the resident safe from other residents entering his room when he felt he could not defend himself, did not obtain any witness statements or interview others regarding residents wandering into resident rooms. (See resident #44 interview below regarding additional potential violations involving MANE.) On 10/13/15 at 4:12 p.m., conslt #2 stated another investigation was conducted at the same time as the above investigation to see whether residents felt safe at the facility and to determine if there were residents who were fearful or felt in danger. He confirmed there was not any available documentation provided in the investigation folder during the survey process to refer to another investigation for statements or interviews. The conslt stated the uninvited resident listed in the allegation was no longer residing at the facility and the conslt acknowledged there was no available documentation provided in the investigation folder to indicate this. The conslt further confirmed there was no summary of the investigation, no interventions offered or planned to address the resident's safety concerns, and neither a complete nor thorough investigation of the incident and how the facility planned to prevent further incidents from occurring. 5. Additional allegations of potential violations involving MANE since 10/13/15 On 10/23/15 at 12:57 p.m. resident #44 was interviewed again. He reported resident #133 had come into his room four times the day before. He reported staff will come in and try to get her out of the room but he will frequently have to wait a long time because they are understaffed. He reported the resident will come into his room and yell and scream and say nonsense. He reported the resident had come into his room the day before four times; once during the day and three times at night. He reported he had witnessed the resident swinging at staff when they had tried to get her out of his room and it made him nervous. He stated, I have seen her get in a fight with another resident, I have seen her run around and hide, grab stuff off the walls, yell and say nonsense and go into other residents' rooms. When she came into my room I yelled get out and started pounding on the call light. She started coming towards me and I was scared. Cross reference F323; accident hazards/resident to resident abuse. C. Resident #76 Resident #76, age 73, admitted into the facility on [DATE] and readmitted again on 1/21/15 with [DIAGNOSES REDACTED]. The 10/6/15 MDS revealed the resident was unable to complete a brief interview for mental status and staff completed on the resident's behalf. The staff assessment for mental status (SAMS) identified the resident had short and long term memory problems although the resident had the ability to recall current season, location of own room, staff name and faces, and that she resided in a nursing home. The resident had signs and symptoms of [MEDICAL CONDITION] with continuous disorganized thinking and fluctuating inattention and altered level of consciousness behaviors. 1. Allegations involving MANE On 10/6/15 at 3:09 p.m., resident #101 was interviewed. He stated there were times in the facility he felt mentally and emotionally distressed. He stated resident #76 routinely threw items in the dining room with residents present when she was upset. He stated when the resident was in a bad mood, residents had to protect themselves because the staff allowed the resident to act out instead of dealing with the resident ' s behaviors. The resident stated he reported these events to staff. The resident was concerned about the behaviors observed by resident #76. On 10/7/15 at 2:39 p.m., CNA #18 was interviewed. The CNA confirmed resident #76 was known to throw dishes and become agitated in the dining room. On 10/8/15 at 9:46 a.m., CNA #5 was interviewed. He stated he saw resident #76 throw cups in the dining room and verbally abuse residents in the dining room. He said residents have reported to him feeling scared when resident #76 was seen having behaviors. The CNA reported he informed the floor nurses when residents reported feelings of being scared or afraid and when residents acted out or had inappropriate behaviors. On 10/8/15 at 10:14 a.m., CNA #20 was interviewed. The CNA confirmed resident #76 threw plates in the dining room. The CNA said they did not know what triggered this behavior. She stated resident has thrown water also. The CNA stated there was a nurse on duty during each meal service. She stated the nurse was to remain in the dining room during meal service to assist and observe meal service. The CNA said residents have told her they do not feel safe when resident #76 was exhibiting behaviors. On 10/8/15 at 1:26 p.m., LPN #2 was interviewed. She said incidents reports (SBAR) were completed for falls, skin tears, and bruising, unsafe smoking behaviors, elopements and aggressive behaviors towards staff or residents; she did not indicate incident reports were completed or incidents were reported when residents expressed aggressive behaviors that had the potential to cause injury. On 10/8/15 at 1:41 p.m., LPN #5 was interviewed. She stated nurses were expected to report residents' aggressive behaviors to the NHA or DON. She said some residents have told her they were afraid of getting hit when resident #76 threw things in the dining room. On 10/8/15 at 4:01 p.m., the resident #101 was interviewed again. He stated he felt resident #76 was violent. He stated he felt he and other residents at the facility were in danger when the resident acted out and some residents felt the resident could go after them. The resident stated during the time he was recovering from an accident, he felt the resident could have easily hurt him. The resident did not feel the facility had the accommodations to meet the needs of resident. The resident felt the facility did not provide adequate reassurance to residents after violent outbursts observed by residents at the facility. 2. Record Review: a. Progress Notes A review of resident #76's progress notes from 8/19/15 to 9/13/15 revealed on 9/4/15 and again on 9/13/15, the resident was observed in the dining room throwing coffee mugs onto the floor and pouring cups of water onto the dining room tables, threw a plate at a staff member; was cursing, screaming, and throwing cups. b. Investigation On 10/7/15 at approximately 5:00 p.m., a request was made to the NHA for investigations related to resident #76 regarding the above incidents. On 10/8/15 at 3:10 p.m., the NHA, consultants (Conslt) #1 and #2, and DON provided an investigation which consisted of the following: - Progress notes from 4/2/15 through 9/19/15. In pertinent part: The 9/4/15 progress note revealed, .resident noted in her room with the door closed using foul language, then opening/closing her room door loudly and shouting/cursing; resident out of her room into the dining room collecting cups and into the main lobby collecting flower decorations and taking them to her room; noted at the coffee area in the dining room tearing open and putting numerous packets of sugar into a cup of coffee, then proceeded to throw coffee mugs onto the floor and shattering multiple mugs along with pouring cups filled with water onto the dining room tables .shaking her fists at residents while cussing and yelling . The 9/13/15 progress noted showed, .(Resident) then went into dining room and started filling up several cups with water and juice and took some back to room. (Resident) then came into the dining room requesting her tray and when staff explained to (resident) her tray was in her room; (resident) began cursing and screaming. (Resident) then threw a plate at (LPN #5). (Resident) was escorted to a table and an extra tray was given to (resident), she dumped her plate on the table and went to get more juice and started throwing the cups. (Resident) started to curse out other (residents) that were eating . c. Failure in facility investigation of allegations involving MANE The DON stated she searched the resident ' s record and could only produce the progress notes from 4/2/15 through 9/19/15. She expressed in her search for information, she could not find a single SBAR in the resident ' s medical record. The facility did not have any witness statements or interviews from staff or residents regarding the above incidents. There were no summary findings of investigations; the facility did not attempt to determine the root cause or discuss interventions or implementation of new interventions following the resident's behaviors on 9/4/15 or 9/13/15. The facility had a progress note from 9/19/15, labeled, (at risk review) (ARR) because resident had increased behaviors. There was no follow-up information, no plans to ensure residents' safety from resident #76's behaviors made available in the resident's chart after the ARR.

Based on resident and staff interview, observations, and record review, the facility failed to promote care for five (#3, #28, #88, #132, and #56) of six out of 47 total residents sampled in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality. Staff failed to respond to resident requests in a respectful manner, enter resident rooms in a respectful manner or ensured resident permission, as well as privacy, with cares. Resident #3 sat in urine for five hours which, in addition to incontinence, frustrated, angered and embarrassed her and made her feel less important than other residents. The findings include: I. Facility's policies and procedures (P&P) On 10/9/15 at 10:48 a.m. a copy of the Resident Dignity & Personal Privacy P&P was received from the Director of Nursing (DON). The Resident Dignity & Personal Privacy P&P (revision date 6/07) documented the following, in pertinent part: The facility provides care for residents in a manner that respects and enhances each resident's dignity, individuality, and right to personal privacy. Each resident's right to personal privacy includes the confidentiality of his or her personal and clinical affairs. Dignity means that when interacting with residents, staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth .Knock on doors before entering, announce your presence .Groom appropriately and to resident's desire .Drape and dress residents appropriately at all times to avoid exposure and embarrassment . II. Resident #3 A. Resident Status Resident #3, [AGE] years old, was admitted to the facility on [DATE] with the following diagnoses, according to the face sheet: diabetes mellitus type II, chronic pai[DIAGNOSES REDACTED], restless leg syndrome, overactive bladder, dyspnea, history of urinary tract infections (UTIs), and migraines. The 8/12/15 admission minimum data set (MDS) documented the resident's brief interview for mental status (BIMS) score was 12 out of 15, which indicated that her cognitive status was moderately impaired. She required extensive assistance of one to two persons with bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. She was not on a special toileting program. She was frequently incontinent of bladder and always continent of bowel. On 8/22/15 (last updated) the incontinence care plan documented that the resident had occasional incontinence. The interventions included, Activities: notify nursing if incontinent during activities. Clean peri-area with each incontinence episode. Encourage fluids during the day to promote prompted voiding responses. Ensure the resident has unobstructed path to the bathroom. Establish voiding patterns. Staff to offer prompted toileting upon arising, before and after meals, at bed time, and as requested per resident. Hand washing before and after delivery of care. Have call light within easy reach. Observe/document/report PRN (as needed) any possible causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke, and medication side effects. The care plan did not include the resident was wearing incontinence briefs. On 8/6/15 the bowel and bladder assessment documented that the resident was cognitively intact. She was able to be understood and understand others. She was incontinent at times with bladder. She would leak urine with physical stress. She occasionally had urgency. She was not able to determine how long she could hold her urine stream. She was not able to determine if she could empty her bladder. She was not able to determine if she had the urge to go to the bathroom but was able to feel urine passing. She was able to determine if she was wet. The possible contributing factor included her history of UTIs. She was independent with accessing food and fluids. The resident did not want to participate in the bowel and bladder program and the risks/benefits had been discussed with her. The overall plan was to continue to monitor her bowel and bladder status. The undated Kardex documented that the resident was continent of bowel and frequently incontinent of bladder. No toileting considerations were documented. The directive to staff on the care plan, to offer prompted toileting upon arising, before and after meals, at bed time, and as requested per resident, was not referenced. B. Resident interview On 10/6/15 at 2:53 p.m. the resident reported the interview might be interrupted by the Certified Nursing Aides (CNAs) because she had told them at 11:00 a.m. that she needed to use the bathroom. She said the CNAs tell her she has to wait until the next shift before she can get assistance with toileting. She reported it made her mad and frustrated when she needed to go to the bathroom. She said the staff told her she had to wait until other residents who needed more assistance were taken care of before they could help her. She stated this made her feel like she was not important, that the staff did not care that she had to sit in her urine. She said the long waits led to incontinent episodes. She said, Who wants to sit in their own pee and poop. It's disgusting. Why won't they help me so I don't have to run around smelling like this? She said she felt dirty all the time. She then stated she had to go to the bathroom and propelled her electric wheelchair down the hallway to find staff but before she left she repeated she that she had asked the CNAs to assist her to the bathroom around 11:00 a.m. but they had not responded yet and said staff would make her wait until the next shift. At 3:44 p.m. the resident was interviewed again and said the staff had not responded to her request to use the bathroom. She turned on the call light at 3:44 p.m. so she, again, could request to use the bathroom. She repeated that she had been waiting for assistance since 11:00 a.m. when she first requested to use the bathroom. C. Observations 1. 10/6/15 On 10/6/15 at 3:45 p.m. Registered Nurse (RN) #1 responded to the resident's call light and asked the resident what she needed. The resident told her that she had asked the staff at 11:00 a.m. to assist her in using the bathroom but no one had come to help her. The RN was overheard saying to the resident that she would keep the call light turned on so she could time the CNAs' response times to the call light. The resident agreed and stated, Watch they will come answer it, but tell me I have to wait until the next shift. The RN found two CNAs in the hallway and asked them to provide assistance to the resident. At 3:54 p.m. CNA #16 responded to the call light. The resident told her that she had needed to go to the bathroom since 11:00 a.m. The CNA did not respond to the resident's statement. The CNA closed the door. The CNA asked if her partner, CNA #13, was aware that the resident needed to use the bedpan. The resident said, I hope, since I told her at 11:00 a.m. At 3:59 p.m. CNA#16 went to find CNA #13 to assist with the resident's cares and transfer. At 4:01 p.m. CNA #16 returned to the room with the Hoyer lift. At 4:04 p.m. the resident asked CNA #16 to go and find the other CNA. CNA #16 left the room. At 4:06 p.m. both CNAs returned to the resident's room. They began transferring the resident to her bed using the Hoyer lift. At 4:07 p.m. the resident's incontinence brief was observed; it was soaked with strong malodorous smelling urine and some liquid stool. At 4:17 p.m. to 4:23 p.m. staff stood in the hallway waiting for the resident to use the bedpan in private. At 4:36 p.m. the CNAs transferred the resident from the bed to the wheelchair using the Hoyer lift. The resident then continued on to an activity. On 10/6/15 at 4:31 p.m. CNA #13 reported that she had worked with the resident for the past month and CNA #16 had worked with the resident since the resident's admission. 2. 10/7/15 On 10/7/15 at 2:27 p.m. the resident was observed asking CNA #4 to assist in taking her to the bathroom. The CNA told the resident the next shift was coming on in three minutes to four minutes so they could help her. The CNA reported that she would notify the next shift so they could assist her first. The resident stated, This is what I mean. They always tell me the next shift will do it. At 2:29 p.m. CNA #4 brought the Hoyer lift and parked it in the resident's room. She closed the resident's door while the resident remained in hallway. She eventually left the room and walked down the hallway. At 2:41 p.m. the next shift of CNAs had arrived and were doing report and rounds with each other. No one stopped to tell the resident if they were aware of her need to use the toilet. At 2:42 p.m. CNA #16 stopped by and spoke to the resident. The CNA asked the resident if she would be able to wait for assistance to the bathroom until 4:00 p.m. The CNA told the resident that she was sorry for the delay, but she was assigned to do one on one sitting with another resident and could not leave her. The CNA then ran after the resident for whom she was providing one to one sitting. The resident stated, What did I tell you? They always tell me to wait for the next shift or wait many more hours than what I've already waited. She said, This is what they (CNAs) do all the time. This tells me that my needs aren't as important as the other residents' needs. This isn't fair that I have to sit in my urine for all this time. The resident said this happens to her all the time. She reported it made her embarrassed that she has to sit in her urine and feces for long periods of time. She said she used to get really angry about it but now she knew it would not do her any good, so she had resolved herself to the fact that the CNAs would not help her go to the toilet unless the other residents' needs had been taken care of before hers. At 2:56 p.m. she put her call light on and stated, I don't know if the CNAs understand that I have to go to the bathroom? At 2:58 p.m. Licensed Practical Nurse (LPN) #5 answered the call light but did not turn the call light off and did not offer to take the resident to the toilet. The LPN said she would let the staff know that the resident needed to use the toilet. The resident told her that the CNAs had told her she had to wait until 4:00 p.m. before they could help her. The LPN reported that she would tell the CNAs to help her now. At 3:04 p.m. CNA #16 and CNA #8 arrived at the resident's room. CNA #16 said she had to borrow CNA #8 from another unit because her partner was busy with other residents. At 3:11 p.m. the resident reported that she was incontinent a lot and usually soaked her pants because of how long she waited for assistance. The resident stated she had wet herself while waiting for the staff to help her. The CNAs got the resident transferred to bed from the wheelchair. The incontinence brief was saturated with urine but not malodorous. At 3:20 p.m. and until 3:28 p.m. the resident used the bedpan in private. CNA #8 reported that she was not familiar with the resident's routine because this was not her usual hall to work. At 3:31 p.m. CNA #8 provided peri-care. The resident's skin was intact but red. At 3:34 p.m. both CNAs agreed that the Hoyer sling was too large for the resident. CNA #16 asked the resident if she could use the over sized sling on her for this transfer. The resident stated she had slid out of the over sized sling once before and did not want to use the sling. The CNA tried tucking it under the resident but the resident became agitated and said, No! I told you I slipped out of the blue one. I don't want another fall. At 3:40 p.m. CNA #8 reported that she would have to go find another sling and would return shortly. At 3:41 p.m. CNA #8 returned with the correct sized sling. The CNAs transferred the resident from the bed to the wheelchair. D. Staff Interviews On 10/7/15 at 4:24 p.m. CNA #16 said she had worked at the facility for the past ten years. She reported she had worked with this resident since the resident's admission. She said her normal assignment was on hallway three where resident #3 resided. -She said there was plenty of staff and she sometimes had to wait for assistance from other staff members because it took two persons to transfer the resident. She reported the CNA workload on hallway three was heavy during certain times of the day, like at shift change, so residents needed to wait for assistance because they were not able to assist everyone at once. She said she did not have to borrow staff from another unit often. -She stated resident #3 would wait until change of shift before asking for assistance so it made it hard for the staff to help her in a timely manner. She reported they usually worked with the resident to determine the time she wanted assistance to the bathroom. She said she did not feel the resident had to wait a long time for assistance but could not speak about what occurred on the day shift. She stated the resident had complained to her frequently in the past that day shift would refuse to help her to the bathroom and would tell her to wait for the next shift. She said she had not reported this information to the nurse or to management. -She stated that a resident's continence status was documented in the computer system. She said CNAs were responsible for charting every time they took someone to the bathroom. -She said the resident was a mix of continent and incontinent and the resident was not able to make it to the bedpan all the time. She stated staff took the resident to the bathroom at least three times on her shift (evening shift). She further stated she felt the resident waits until the evening shift to use the bedpan because evening shift staff was most willing to transfer her frequently. On 10/13/15 at 8:18 a.m. the Director of Nursing (DON) reported she would expect her staff to check on the resident for toileting needs every two hours and on an as needed basis like for all residents. She said she would expect the CNAs to assist the resident with toileting needs upon her request and not make her wait. On 10/13/15 at 11:26 a.m. CNA #17, who worked the day shift, reported she had worked at the facility for eight years and hallway three has been her assignment. -She said she works with the resident on establishing a time to take her to the toilet because it requires two staff to transfer the resident. She said they are not always able to take her to the toilet when she requests it because two CNAs have to be available at the same time. She stated she responds quickly to the resident's call light and request for toileting, but explains to her that she has to wait until she could get the Hoyer lift and the other CNA. She said she felt the resident understood this. -She reported the resident is transferred to the toilet on average twice her shift. She reported that sometimes it is less than twice a shift because the resident would not request to be toileted. The resident was not a toileting program and was not being monitored every two hours since she was independent and able to communicate if she needed assistance with toileting. On 10/13/15 at 11:16 a.m. LPN #5, who worked the day shift on hallway three, said the CNAs were attentive to resident #3's requests to be toileted. -She stated the CNAs work out a time with the resident since she requires two staff for transfers. She reported she was not aware the resident was waiting five hours or longer between continence checks. -She said the resident was independent and would be able to communicate the need to toilet so she would not expect the staff to have her on a special schedule to ensure she was toileted. She reported she would have to educate the resident to not wait such a long time between toileting. She was not aware the staff was asking her to wait the long periods of time for staff assistance. On 10/13/15 at 11:44 a.m. CNA #4, who worked the day shift on hallway three, reported the resident usually asked for assistance during change of shift or during the meal. She said if they had more staff, they might be able to accommodate her needs more timely. She stated it was difficult to take the resident to the toilet during busy times of day because the resident's transfer required two persons and a lift. -She said the CNAs usually worked with the resident to set up a time for toileting. She reported that the resident was not a toileting program and the resident did not require special treatment with toileting because she could report her needs to the staff. -She stated the resident was taken to the toilet on average once a shift. She confirmed she had asked the resident to wait for the oncoming shift when she had a few minutes left to her shift. She said overtime work was not accepted by management. III. Resident #28 A. Resident Status Resident #28, age 63, admitted into the facility 1/7/11 and again on 11/8/12 with [DIAGNOSES REDACTED]. The 8/8/15 MDS assessment revealed the brief interview for mental status (BIMS) score of 15 which indicated the resident's cognition was intact. Section J (Health Conditions) showed resident received scheduled pain medication and received as needed pain medication. During the review period, the resident reported pain was almost constant; made it hard to sleep at night, limited his day to day activities and the resident reported work pain level was a ten on a scale of zero to ten. The resident had a life expectancy of six months or less. B. Observation On 10/6/15 at approximately 4:40 p.m., the resident reported he still needed his 4:00 p.m. pain medication. The resident wanted to remind the nurse of his scheduled medication and propelled himself from the milieu area towards the 200 hallway where he resided. The resident approached LPN #6 who was scheduled to work on a hallway other than 200. The resident was positioned directly in front of the LPN when he called out the LPN's name. The LPN in the milieu looked directly at the resident then looked around other hallways. The LPN did not acknowledge the resident as he called out the LPN's name four times within two feet from the LPN. The LPN did not acknowledge the resident, did not request the resident to hold on, but rather ignored the resident's attempt to gain his attention. C. Interviews On 10/6/15 at 4:47 p.m., the resident stated LPN #6 ignores him when he tries to ask the LPN a question. The resident said it was common for him to approach staff and feel ignored. Alternatively, they often tell him they are busy with something else. On 10/9/15 at 11:29 a.m., the resident was interviewed again. He stated he did not feel the facility provided him the care he deserved. He stated staff routinely told him to wait a minute as they helped others. He felt if he waited every time he was told to hold on by staff, things he needed to get done wouldn't be addressed. On 10/13/15 at 11:20 a.m., the director of nursing (DON) was interviewed. The DON stated staff should acknowledge residents when approached and help from staff was needed. She said residents should not feel ignored in their home and should be treated respectfully and in a dignified manner. The DON stated the LPN should have acknowledged the resident to show the resident's needs mattered to the LPN. IV. Resident #88 A. Resident Status Resident 88, age 82, admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The 9/19/15 MDS assessment showed a BIMS of eight out of 15. The resident's score indicated her cognition was moderately impaired. Section F (Functional Status) showed the resident was independent with transfers, locomotion on/off unit, and no impairment or limitation in range of motion of upper and lower extremities. Section E (Behaviors) reported the resident did not exhibit wandering behaviors. B. Interviews On 10/7/15 at 8:49 a.m., the resident said staff enter her room without knocking. She felt she was not treated in a dignified and respectful manner. The resident felt when staff came in to help her roommate, staff did not acknowledge her presence, did not greet her or offer her any assistance when they were in her room. The resident felt she deserved a better service and staff should see how she was doing. C. Observation On 10/7/15 at 9:15 a.m. the activity manager (AM) walked into the resident's room without knocking or announcing her presence. The AM had mail in her hands as she entered the resident's room. The AM said she walked into the room without knocking because she did not know anyone was in the room. She said she was in the room to deliver mail, then placed a few pieces onto the roommate's bed and exited the room. The resident said it was the first time the AM had spoken to her and it wasn't common for the AM or other resident's to say anything before they entered her room. Subsequently, on 10/9/15 at 11:12 a.m. and 11:14 a.m., LPN #6 entered room [ROOM NUMBER] without knocking each time the LPN entered the room to administer medication. D. Staff Interview On 10/9/15 at 12:18 p.m., the social services director was interviewed. The SSD said she expected staff to knock before they entered a resident's room. She stated the facility was the resident's home and that staff, in failing to knock, were not treating residents in a dignified manner. On 10/13/15 at 11:20 a.m., the DON said she expected staff to knock on resident doors before they enter a room. She stated staff's failure to knock on doors or acknowledge the resident after entering was a dignity issue. The DON said residents deserved to be treated in a respectful and dignified manner. V. Resident #132 A. Resident Status Resident #132, age [AGE] years, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A comprehensive assessment had not been completed for the resident as the resident was newly admitted to the facility. The resident transferred to another facility on 10/7/15. B. Observation On 10/7/15 at 9:39 a.m., registered nurse (RN) #3 entered the resident's room without knocking and requesting permission to enter. The RN announced to the resident that she was going to change the resident's catheter. Without pulling the privacy curtain, the RN pulled down the covers and pulled up the resident's hospital gown, exposing the resident's incontinence brief. The resident stated she was embarrassed the nurse had to do this. The RN commented she was accustomed to this because it was part of her job. C. Staff Interview On 10/13/15 at 5:18 p.m., an interview with the nursing home administrator (NHA) in the presence of consultant (conslt) #2 revealed that it was his expectation that staff knock and await permission to enter a resident's room. The NHA stated that it was not acceptable for the nurse to begin providing intimate cares to a resident without first providing for privacy and obtaining resident consent for the procedure. The NHA acknowledged the interaction between resident #132 and RN #3 did not meet his expectations. VI. Resident #56 A. Resident Status Resident #56, age [AGE] years, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The 8/13/15 admission minimum data set (MDS) assessment revealed: -The resident had short and long term memory impairment and was severely impaired with decision making. -The resident could not recall current season, location of room, staff names/faces, or that she was in a nursing home. -The resident exhibited signs and symptoms of [MEDICAL CONDITION] that included inattention and disorganized thinking. - The resident did not exhibit [MEDICAL CONDITION]. -The resident had other behavior symptoms not directed towards others on one to three days of the observation period. -The resident did not exhibit rejection of care during the observation period. -The resident required extensive assistance from two staff for bed mobility, transfers, locomotion on and off the unit, dressing toileting, and personal hygiene. -The resident was frequently incontinent of bladder and always continent of bowel. -The resident had a [DIAGNOSES REDACTED]. The 8/22/15 incontinence care plan stated that the resident was incontinent related to confusion and dementia. The goal was that the resident would not develop impaired skin integrity r/t (related to) incontinence through the next review date. The approaches included: -Activities: notify nursing if incontinent during activities. -Clean peri-area with each incontinence episode. -Prompt toileting upon arising, before and after meals, at bed time, and prn. B. Observations On 10/8/15 at 11:01 a.m., the resident was observed to be awake and wheeling in her chair in the library. There were wet spots on the front shins of her pants from weeping [MEDICAL CONDITION]. A dried wet spot was present on the right side of the resident's lap. On 10/8/15 at 11:23 a.m., the resident was escorted to her room by LPN #6 and registered nurse (RN) #4 for observation of the resident's shins and wound care. The RN, who was working the floor as an aide, was initially present to assist the LPN with any cares, but then left to contact hospice about the resident's weeping [MEDICAL CONDITION]. After completing observation of the resident's shins and wound care to the left stasis ulcer, the LPN left the resident in the pants with the wet shins and the dried wet spot on the right lap. The LPN escorted the resident to dining room to wait for lunch. On 10/8/15 at 12:55 p.m., the resident was escorted to her room by CNA #9. CNA #9 acknowledged the dried wet spot on the resident's right lap area. The CNA stated she did not know what caused the wet spot to the lap. The wet spots on the shins were smaller and drying after the wound care. CNA #14 arrived to assist with transfer and cares. Each CNA denied providing perineal/toileting care to the resident that shift. The CNAs were unable to state when the resident was gotten up from bed because, they reported, the hospice CNA was provided the morning cares to the resident that morning. The CNAs acknowledged they were each responsible for a whole hall of residents that morning. Examination of the resident's pants and brief after cares revealed the pants had dried wetness inside and outside of the lap area. The brief was wet with urine. The CNA stated the resident is supposed to be changed every two hours but that this was not always possible when they were not fully staffed. C. Staff Interviews On 10/8/15 at 4:48 p.m., an interview with the DON revealed that it was her expectation that residents received toileting as needed and that residents were kept clean and dry. The DON stated that LPN #6 should have assisted the resident to change or should have obtained a CNA to assist the resident to change her pants and brief after wound care on 10/8/15. The DON stated the dried wet spot on the resident's lap could have been from urine leaking from the resident's brief and a change of brief should have been completed prior to lunch. The DON stated she felt it was a dignity issue to send the resident to lunch in pants with wet shins and a dried wet spot on the lap.

Based on observations, interviews, and record review, the facility failed to ensure that one of three residents with pressure ulcers (#26) out of 47 total residents sampled, received the care and services necessary to ensure healing of an existing pressure sore and the treatment and services necessary to promote healing, prevent infection, and prevent new sores from developing. Resident #26 entered the facility with multiple risk factors for pressure ulcer development, including [MEDICAL CONDITION] (MS) with functional limitations, incontinence of stool, and the presence of a Stage IV pressure ulcer on his left buttock. Staff failed to comprehensively assess, monitor and document information on the status of resident's skin in order to evaluate the effectiveness of treatments. Staff also failed to communicate with the interdisciplinary team (IDT) including therapists and medical providers, regarding measures to relieve pressure, and failed to re-evaluate planned interventions when the resident's existing ulcer failed to heal and he developed three new ulcers. The facility's failures contributed to the formation of pressure areas on the resident's right buttock and heels and to the failure of the wounds, both existing and acquired, to heal. The finding included: I. Resident Status Resident #26, age less than [AGE] years, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The 7/31/15 significant change minimum data set (MDS) assessment revealed: -The resident was cognitively intact as evidenced by a brief interview for mental status score of 15/15. -The resident did not have behaviors that impacted self or others and did not exhibit rejection of care during the MDS observation period. -The resident required extensive assistance from two staff for bed mobility, transfers, toilet use, and personal hygiene. -The resident hand limitations to functional range of motion for one upper extremity and for both lower extremities. -The resident had an indwelling Foley catheter and was frequently incontinent of stool. -The resident had a stage one or greater pressure ulcer; was at-risk of developing additional ulcers, and an unhealed stage III which was not present on admission/re-admission, an unhealed stage IV pressure ulcer that was present on admission/re-admission; and one unstageable/deep tissue injury. -The dimension of the stage IV in centimeters was 3.0 length (L) x 4.2 width (W) x 2.8 depth (D) -The stage III and stage IV ulcers were present on the previous assessment. -The resident had a pressure relieving device to his bed, his chair, received pressure ulcer care, and dressings to the feet. -The resident was 68 inches tall and 228 pounds and had not lost or gained weight in the last six months. The 8/11/15 pressure ulcer care plan for the resident stated the resident had a stage IV pressure ulcer to his buttock related to disease process of [MEDICAL CONDITION], being wheelchair bound, impaired mobility, and incontinence. The resident care plan stated the resident also has a stage 3 to hip area. The care plan stated the stage IV ulcer had had infection with osteo[DIAGNOSES REDACTED] (bone infection). The goal was for the resident to have the infection treated and healed with intravenous antibiotic therapy and current wound treatment. The approaches were: -Administer medications as ordered. Observe/document for side effects and effectiveness. -Administer treatments as ordered and observe for effectiveness -Complete a full body check weekly and document -Encourage resident to Reposition in chair frequently for comfort and pressure reduction -Follow facility policies/protocols for the prevention/treatment of [REDACTED]. -IDT (interdisciplinary team) referrals as indicated, i.e., RD (registered dietitian), PT, OT (physical and occupational therapy) -Observe nutritional status. Serve diet as ordered, observe intake and record. -Obtain and observe lab/diagnostic work as ordered. Report results to MD (medical doctor) and follow up as indicated. -Provide incontinence care after each incontinence episode, or per established toileting plan -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudates. The care plan did not address and was not updated to reflect the presence of the pressure areas to the resident's bilateral heels and right buttock. (See record review below) II. Resident Interview On 10/13/15 at 10:53 a.m., an interview with the resident revealed: -The resident stated he arrived at the facility with one pressure ulcer to his left buttock. According to the resident, the left ulcer developed when he was at home and resulted in his admission to the hospital and then another facility prior to admitting to the current facility. -The resident stated he did not want to get anyone in trouble, but his wound to the right buttock and both of his heels developed while he was a resident at the facility. -The resident stated that since arriving at the facility, he had been on the same air mattress and in the same wheelchair with the same wheelchair cushion. The resident stated he got up in his wheelchair and was in his wheelchair whenever he was out of bed in the afternoon. -The resident stated he had not been approached by the IDT since admission and he had not been screened for devices to prevent further skin breakdown to his heels or buttocks while in bed or up in his wheelchair. III. Observations On 10/6/15 at 4:02 p.m., the resident was observed in his wheelchair. The wheelchair was both too high as evidenced by his feet not touching the floor and too wide to fit the resident comfortably. The resident was slumped to his right with his head on his right hand. The resident stated that the wheelchair was too big. On 10/9/15 at 1:45 p.m., the resident was observed in his room. The resident was in his wheelchair. The chair was three to four inches too wide for the resident at the side. The resident's feet did not touch the floor. A black one to two inch thick cushion was in place in the seat of the wheelchair. On 10/9/15 at 3:56 p.m., licensed practical nurse (LPN) #4 and registered nurse (RN) #5 were observed while providing care to the resident's pressure wounds. Observation revealed: -The dressing was removed from the right buttock pressure ulcer (acquired after admission). The wound base had thick, yellowish/brown eschar and red meaty tissue to the wound walls. The top of the wound had black eschar. The wound appeared deep but without tunneling. -The left buttock pressure ulcer (present on admission) had a red meaty center and was small in diameter. The peri-wound skin was sheared from the drape and was red and weeping serous (clear) fluid. His skin had scabs from the drape on his skin. -The wounds were each cleaned, dressed and [DEVICE] applied following physician orders [REDACTED]. -During the change to the right buttock wound, the RN stated to the LPN that she noticed last time she changed the dressing that the tissue had adhered to the dressing and had torn the new tissue. The RN reported that the resident has skin that is sensitive to tape. -The RN stated that one challenge for healing the resident's wound was that the resident could have five bowel movements a day. The bowel movements often contaminated the wound vac and necessitated additional changes to the wound vac. No measurements were obtained during the wound care. Wound care to the heels was not offered at this time and heel wounds were not observed. III. Record Review Review of admission documents, Skin-Weekly Pressure Ulcer Records, Head-to-Toe Skin Checks, Daily Skilled Nursing Notes, and Nurse's Notes revealed the resident acquired three additional pressure ulcers after admission. These pressure ulcers, as well as an existing pressure ulcer on admission, did not heal. Record review revealed the ulcers were inadequately documented to monitor progress and the effectiveness of treatments. Care plan interventions (see above) were not implemented or revised when new ulcers developed. A. Admission Documents -The 4/29/15 history and physical from the resident's previous facility revealed that the resident had, a decubitus (pressure) ulcer on his left buttock with vacuum in place. -The 5/18/15 at 9:41 p.m., and 2:35 p.m., nursing notes from the previous facility stated the resident had a [DEVICE] (vac) in place on his left buttock. -Other notes from the previous facility in the admission documentation showed the presence of a stage IV pressure wound to the resident's left buttock/coccyx area and that the wound had been infected on admission to the hospital in April 2015. B. Skin/Wound Documentation 1. Skin-Weekly Pressure Ulcer Record -The 6/16/15 record, which was the first such record available in the resident chart since his admission 5/19/15 with a Stage IV pressure ulcer, showed the resident had an existing pressure ulcer on the left buttock. The wound was listed as a stage III that measured 5.5 x 4x4. The wound was 100% granulation tissue. No drainage, odor, or undermining/tunneling was present. The wound edges and surrounding skin were normal. The wound was unchanged. -The 7/8/15 record, which was the next such record available, showed the resident had an existing pressure area on the rear left iliac crest (area above the left buttock) that was present at admission. The wound was a stage IV and measured 4x3x3.2. There was undermining of 1.5 cm at one o'clock. The wound bed was red. There was no drainage or odor. The wound edges were pink and the surrounding skin was normal. The wound was improved, even though undermining was observed which indicated the base of the wound was larger than observed. (See: Kimmel, H and M Pressure Ulcers, http://wound.med.nyu.edu/what-we-treat/pressure-ulcers.) The note stated the resident wound doing well. Treatment changed to effected peri wound area skin. The change was described as, Moist to dry dressing daily and PRN (as needed) apply antifungal cream to peri wound skin [MEDICATION NAME] 100 mg po (by mouth) bid (twice daily) x 10 days. -The 7/15/15 record for the left trochanter (hip) stated the wound was existing and present on admission. The wound was a stage IV pressure ulcer that measured 4.5x2.5x4. The wound bed was normal for the resident's skin. There was a moderate amount of serous (clear body fluid) drainage. No odor was present. The wound edges and surrounding skin were marked as normal for skin. The wound was listed as improved even though it had developed drainage and had an increase in length and depth. The plan was to change treatments and a note stated to see physician orders. -The 7/15/15 record for the right buttock stated the resident acquired a new pressure area in the facility which was first identified on 7/15/15. (But see below for wound identification on 7/13/15) The wound was an unstageable pressure ulcer that measured 4x2.5x0. The wound was in the right gluteal fold area. The wound bed was black. There was moderate serosanguinous (bloody and clear body fluid) drainage present. No odor was detected. The area was debrided to 100% granulation tissue. The wound edges and surrounding skin were marked normal for skin. The plan was to continue to follow (the wound) weekly. The treatment was to be triple antibiotic ointment (TAO) mixed with Santyl covered with a foam dressing that was changed daily. -The 7/15/15 record for the lower extremity stated the resident developed a new pressure area acquired at the facility that was on the left lateral calf per page two of the form but noted on the right lower leg (rear) per page three of the form. The wound was discovered on wound rounds. The wound measured 1x1.5x0 and was unstageable. There was moderate serous drainage from the wound. The wound edges and the wound bed were normal for skin. The plan was to treat the area with a mix of TAO and Santyl, cover with foam and change daily. No additional documentation on this wound was found in the clinical record. The clinical record did not contain any additional documentation on the weekly pressure ulcer form for any of the wounds described above in the 7/13/15 MDS and during observation on 10/9/15 or in the Head-to-Toe Skin Checks and Nurse's Notes below. 2. Head-to-Toe Skin Checks -The 7/13/15 skin check stated that the resident had a new pressure area to the right gluteal fold. The wound was red, purple in color with open area noted. No measurements of the wound were present. No description of the wound bed, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. -The 7/24/15 skin check stated that the resident had existing pressure areas to the left and right buttock. The left buttock wound was 5x3xdeep and a little odor was noticed. The wound to the right gluteal fold was listed as 6mm long. The patient was noted to have an order for [REDACTED]. -The 7/25/15 skin check stated that the resident had existing pressure areas to the right gluteal fold and the left buttock. The wound vac was in place and working for the left buttock wound. The right gluteal fold pressure area was described as an open area. No description of the wound bed, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. -The 8/1/15 skin check stated the resident had existing pressure areas to the left trochanter and the right gluteal fold. No measurements or staging were recorded for either wound. No description of the wound bed, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. The form showed there was a small pressure ulcer to the right gluteal fold and that the wound vac was in place on the left buttock. -The 8/8/15 skin check stated the resident had existing pressure ulcers to the left buttock and right gluteal fold. No measurements or staging were recorded for either wound. No description of the wound bed, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. The form stated Right gluteal folds with large size of wound (sic). Cont(inue) tx (treatment) as ordered. The wound vac was documented to be intact on the left buttock. No description of the wound beds, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. This form did not provide information about the left heel pressure wound that was noted on the 8/5 daily skilled nurse's note (See below) -The 8/15/15 skin check stated the resident had existing pressure and non-pressure areas. The box for new pressure area was not marked, although a new pressure area to the left heel was identified on the form. The form showed the resident had a pressure wound to the left gluteal fold. No further information on the left buttock/gluteal fold wound was documented. The right gluteal fold measured 5x2.5 (no depth was listed) and was stage II. A new pressure area to the left heel measuring 3x2 was listed as a stage I. No description of the wound beds, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. This form did not provide information about the right pressure wound to the resident's heel noted on the daily skilled nurses notes on 8/9 for the right heel. (See below) -The 8/22/15 skin check stated the resident had existing pressure ulcers. The resident had open areas to the left and right gluteal folds that had dressing described as clean, dry and intact. The resident was noted to have a blister on the left heel. No description was provided of the right heel. No measurements or staging were recorded for any wound. No description of the wound beds, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. -The 8/25/15 skin check stated the resident had existing open areas. The wound on the left gluteal fold and right gluteal fold were noted to have dressings that were clean, dry and intact. The form stated the resident had a pressure area to the bilateral heels. The right heel was described as a dark/discoloration. No description was provided of the left heel. No measurements or staging were recorded for any wound. No description of the wound beds, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. -The 8/29/15 skin check stated the resident had existing pressure ulcers. The form showed the resident had wounds to the left and right gluteal folds and the left heel. There was no documentation on the pressure area to the right heel noted on the previous form. No measurements or staging were recorded for any wound. No description of the wound beds, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. The form did not reference the right heel blister that was noted on the 8/27 daily skilled nurse's note. (See below) -The 9/5/15 skin check stated the resident had existing pressure ulcers. The form showed the resident's left gluteal fold wound was pink and the wound was deep. The right gluteal fold wound had slough/ large brown discoloration. The form also showed black discoloration to the right heel and that a problem existed on the left heel. No measurements or staging were recorded for any wound. No description of the wound beds, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. -The 9/12/15 skin check showed the resident had existing pressure areas. The location, measurement, staging of the wounds was not documented. No description of the wound beds, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. The form stated dressings to the buttocks and left heel were changed. -The 9/17/15 skin check showed the resident had existing pressure areas to the left and right gluteal folds and both heels. The left gluteal ulcer measured 2.0x2.0x5.2. The right gluteal fold measured 7.0x6.5x3.0. The left heel measured 1.7x1.8x0.2. No staging was listed for the left heel. The right heel was listed as unstageable and measured as 2.5x1.5x0. No description of the wound beds, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. -The 10/3/15 skin check stated the resident had existing pressure areas. Pressure areas were listed as the left and right gluteal fold and the left and right heels. The form stated Resident has large open area to right gluteal fold and small deep open area to the left gluteal folds. No measurements or staging was recorded for any wound. No description of the wound beds, wound edges, surrounding skin, wound stage, drainage, odor, or other pertinent information was present on the form. 3. Daily Skilled Nursing Notes Daily skilled nursing notes in the electronic record were reviewed for each day that a note was documented. The skilled notes provided a place for nurses to document specific skin concerns including a place to document free text notes and a body map with a table where location and measurements of wounds and stage of wounds could be tracked. Review of the skilled notes revealed inconsistent documentation regarding the location of the resident's wounds, failure to document the presence of wounds, and failure to note changes to the resident's wounds. a. May 2015 -When wound location was recorded, the location most often recorded as having a wound was the right buttock. (See above for documentation that the resident was admitted with a stage IV pressure ulcer to his left buttock) -The 5/19 (admission) note stated the resident had one pressure wound to the coccyx. No measurements for further description was included in the note. -On 5/25, 5/26, and 5/28 no documentation related to the wound was present. -On 5/29/15 2:28 p.m., the note stated, Wound measurements taken by wound RN and wound vac changed per orders. No s/sx (signs or symptoms) infection noted. Resident denied discomfort. -On 5/30/15 10:13 a.m., the note stated, continues with wound vac to right buttocks, with minimal drainage noted at this time, no oder. (Sic) -Measurements, staging, descriptions of the wound condition were not documented in the notes. -Documentation about the resident's wound vac was absent from most notes. b. June 2015 - When wound location was recorded, the location most often recorded as having a wound was the left trochanter. (See above for documentation that the resident was admitted with a stage IV pressure ulcer to his left buttock) -On 6/14 the wound vac was noted to be in place on the resident's right hip. -On 6/18 the wound was noted to be on the sacrum and the wound vac was noted to be in place. -On 6/20 the wound was noted to be on the resident's right rear thigh with a wound vac in place. -No documentation of the wound was present on 6/16, 6/17, 6/19, 6/28, and 6/30/15. -Measurements, staging, descriptions of the wound condition were not documented in the notes. -Documentation about the resident's wound vac was absent from most notes. c. July 2015 -When wound location was recorded, the location most often recorded as having a wound was the left trochanter. (See above for documentation that the resident was admitted with a stage IV pressure ulcer to his left buttock) -The 7/9/15 at 10:30 a.m., note stated, rash to right buttocks, [MEDICATION NAME] ordered, wound vac on hold, wet to dry dsgs (dressing) done. -The 7/13 at 10:05 a.m., note stated there was a new pressure area to the right gluteal fold. -On 7/25 and 7/26 the notes stated the resident had a pressure area to the left lower leg. No additional information about this new wound was found; the left lower leg wound was not recorded as present on any other days that month. - No documentation of the wound was present on 7/2, 7/3, 7/10, 7/14, 7/15, and 7/31/15. -Measurements, staging, descriptions of the wound condition were not documented in the notes. -Documentation about the resident's wound vac was absent from most notes. d. August 2015 -When wound locations were recorded, the locations most often recorded as having a wound were the left and right gluteal folds/buttocks, and the left heel. -On 8/5/15 the record showed the presence of a left heel pressure ulcer. No additional information about the ulcer was documented. Presence of a left heel pressure ulcer was also noted on 8/13, 8/14, 8/18, 8/19, 8/20, 8/28, 8/29, 8/30, and 8/31/15. -On 8/9/15 at 1:55 p.m., the note documented a right heel pressure ulcer. No additional information about the ulcer was documented. -The 8/20/15 at 8:15 p.m., note stated, Dressings to bil(ateral) gluteal fold open area are changed per order after shower. Dressings clean, dry and intact. No s/s of infection noted. No drainage or odor noted. -On 8/27/15 at 2:51 p.m., the note documented the resident had a blister to the right heel. Presence of a right heel pressure ulcer was documented on 8/28 and 8/29/15. -No documentation of the wounds was present on 8/2, 8/3, 8/7, 8/8, 8/10, 8/11, 8/12, 8/15, 8/21 and 8/26/15. -Measurements, staging, descriptions of the wound condition were not documented in the notes. -Documentation about the resident's wound vac was absent from most notes. e. September 2015 -When wound locations were recorded, the locations most often recorded as having a wound were the left and right gluteal folds/buttocks and the right and left heel. - No documentation of the wounds was present on 9/3, 9/4, 9/5, 9/7, 9/12, and 9/18/15. -Measurements, staging, descriptions of the wound condition were not documented in the notes. f. October 2015 -The 10/2/15 at 10:37 a.m., note showed the resident had two coccyx wounds. They were not identified as left or right ulcers. The stage IV coccyx ulcer measured 7x8x2.5 and the stage III ulcer measured 3x3x4. No documentation related to the heel wounds was included in the note. No documentation related to the wound condition, drainage, odor or other pertinent wound data was recorded. -The 10/9 note stated that the resident had wounds to his left and right trochanter. -No documentation related to the resident's wounds were present on 10/1, 10/7, 10/8, 10/10, and 10/11/15. C. Nurse's Notes A review of nurse's notes from 5/19/15 through 7/12/15 revealed no documentation of measurements of the resident's left buttock wound or changes to the condition of the wound since admission. A 7/13/15 at 2:40 p.m., nurse's note showed the resident had a new open area to the right gluteal fold. The physician was notified and treatment was started. A 7/13/15 situation background assessment recommendation (SBAR) nurse's note stated the resident had a new pressure area to this right gluteal fold. The note stated the resident had been sitting up in his chair too long. A 7/16/15 at 3:51 p.m., nurse note stated the resident requested to be sent to the hospital. The resident had a temperature of 101.3 and pulse of 140. An elevated white cell count of 29.8 was noted on the resident's labs. An order was received to send the resident to the hospital. A 7/25/15 at 2:28 a.m., note stated the resident has returned from the hospital. The resident was on intravenous antibiotics and was on isolation for a drug resistant wound infection. A review of nurse's notes from 7/26/15 through 8/7/15 revealed no documentation of the resident's wound measurements, changes to the left or right buttock wound condition. An 8/7/15 note did reveal the resident had been out of the facility that day for an unsuccessful home evaluation. Nothing was documented on 8/8/15 in the nurse's notes about the worsened right gluteal fold pressure ulcer (see above skilled nurse's note) An 8/14/15 at 4:22 pm., note stated the resident's wound vac was discontinued because of frequent bowel movements which necessitated too frequent change of the wound vac. An 8/28/15 and 8/29/15 note stated the resident had wound care to the right and left gluteal folds and to the left heel. A 9/2/15 nurse's note stated the resident had wound care to both gluteal wounds and to bilateral heels. A 9/6/15 nurse's note stated the resident had wound care to both gluteal wounds and to bilateral heels. A 9/10/15 nurse's note stated the resident was in bed and not feeling well. Subsequent nurse's notes through 9/13 showed the resident continued to decline and had a change in cognition. A 9/17/15 at 3:08 p.m., note stated the resident returned from the hospital. The resident was again alert and oriented. A 9/17/15 at 5:41 p.m., note stated resident has pressure area to right heel, hard dry and intact, pressure area to left heel opened with hard dry surrounding, edges a little moist and macerated, minimal drainage noted, area to left gluteal fold open, clean wound bed, vac applied, open area to right gluteal fold with slough noted to base, edges a little red, wound vac applied. A 9/17/15 at 6:20 p.m., note stated the resident needed to be repositioned frequently from side to side for to prevent additional pressure wound areas. A 9/29/15 at 9:41 a.m., note stated the resident was out of the facility for an appointment with the wound clinic. A 10/4/15 at 9:45 a.m., note stated the scab to the resident's left heel fell off. The skin below was moist, pink and intact. The plan was to continue sure prep to the heel for [MEDICATION NAME]. A 10/10/15 at 6:50 p.m., note stated that the resident's skin around wound vac site was irritated due to frequent changing necessitated by the wound vac's contamination with stool. The resident was noted to have multiple bowel movements each day. D. Nursing Admission Data Collection Form The 7/23/15 form showed the resident was readmitted to the facility from the hospital with pressure ulcers to the right gluteal fold (see above; acquired in facility 7/13/15) and the left trochanter (present on original admission 5/19/15 as left buttock). No measurement, staging, description of any wound condition were documented. The 9/17/15 form showed the resident was readmitted to the facility with pressure areas to the left gluteal fold, right gluteal fold, right heel and left heel. No measurement, staging, description of any wound condition were documented. E. Telephone Orders Review of telephone orders confirmed the IDT failed to request a therapy referral to evaluate the resident's mattress, wheelchair or wheelchair cushion as the resident developed new ulcers on his buttocks and heels. Further review revealed delay in seeking treatment orders for newly acquired ulcers. A 7/13/15 order stated cleanse open area to right gluteal fold with wound cleanser, pat dry, apply wound gel, cover with foam dressing change every day. Even though the wound had increased in size on 8/8/15. there was no telephone order evidencing a change in wound treatment or request for a PT referral to address the resident's need for pressure relief to his buttocks, now with ulcers on the right and left buttock An 8/14/15 telephone order stated that the wound doctor needed to consult the infectious disease doctor for a plan of care for the resident's wounds. An 8/14/15 telephone order directed a wound vac change ever Monday, Wednesday and Friday and as needed to the right buttocks. The wound vac was to be set at 125mm of suction. An 8/14/15 telephone order directed cleanse left gluteal fold with wound cleanser, pat dry, place wet to dry dressing then cover and secure with tape. Change twice daily for wound care. An 8/26/15 note stated the resident needed to have an appointment with the wound clinic for the right and left gluteal fold wounds and the left heel wound. Again, there was no evidence a referral was requested for therapy to evaluate the resident's mattress, wheelchair or wheelchair cushion An 8/28/15 telephone order directed staff to cleanse right ischium with wound cleanser, apply [MEDICATION NAME], and apply foam dressing daily. An 8/28/15 telephone order directed staff to cleanse right gluteal fold with wound cleanser, pat dry, apply Santyl ointment, and cover with foam dressing once daily. An 8/28/15 telephone order directed staff to cleanse left heel wound with wound cleanser, pat dry, apply sure prep to skin around open area, and apply wound gel to open area then cover with border gauze once daily for wound care. A wound to the left heel was initially identified on 8/5 and then again on 8/13, 8/14, 8/18, 8/19, and 8/20/15. (See skilled nursing documentation above) An 8/28/15 telephone order directed staff to apply sure prep to intact blister on right heel twice daily for wound care. A wound to the right heel was first identified on 8/9 and then again on 8/23 and 8/27. A 9/4/15 telephone order directed staff to send the resident to the wound clinic for an evaluation and treatment. A 10/9/15 telephone order directed staff to send the resident for a surgical consult for a diverting [MEDICAL CONDITION] to help with the healing of his gluteal pressure ulcers. F. Treatment Administration Record (TAR) The 5/15 TAR showed an order for [REDACTED].

Based on observation, record review, and resident and staff interviews, the facility failed to provide care and services to attain or maintain the highest practicable physical well-being for one (#40) of three residents reviewed for pain management out of 35 sample residents. Specifically, the facility failed to: -Adequately respond to the resident's pain; -Provide timely pain assessments; -Provide timely pain management treatments as ordered; -Document the resident's level of pain; -Document the resident's refusals of PRN medication; and -Notify the physician when the resident's pain regimen was not working. These failures contributed to the resident experiencing unrelieved pain that he rated 8/10 to 10/10, and stating that he was constantly in pain, and that he hurt so much he stayed in his room all day. The findings: 1. Facility pain management policy: The pain management policy required in pertinent part: -Upon admission, then quarterly, annually and when there was a significant change, residents would be assessed for pain. The evaluations would be used by IDT (interdisciplinary team) for determination of the appropriate therapeutic interventions which would include pharmacological and non-pharmacological techniques. The policy further indicated that if any resident reported inadequate pain control or if the resident was identified with new onset of pain, that resident would have a full evaluation of pain conducted. -The Policy further indicated that following that pain evaluation, the physician would be notified of the findings and those findings and notification would be documented. Each resident with pain was to have an individualized care plan in place. -The Licensed nurse would document the Medication Administration Record (MARs) of pain, medication, interventions and outcomes for all pain medications administered. The staff was to implement the care plan, monitor the resident, and administer therapeutic interventions for pain as ordered. Effectiveness of routine scheduled pain medications was to be documented on the back of the MAR or in nurse's notes each day. 2. Resident #40 Resident #40, [AGE] years old, was initially admitted to the facility on [DATE]. According to the resident's admission face sheet, he had [DIAGNOSES REDACTED]. The medical record indicated that the resident experienced chronic pain. The current minimum data set (MDS) assessment dated [DATE], documented the resident understood others and others understood the resident. The resident scored 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact for daily decision making. The MDS also indicated the resident had no delusions and no behavioral symptoms. The resident received scheduled but no PRN (as needed) medications and received no non-pharmacological pain management regiment. The resident experienced pain occasionally, at a pain level of 4/10. The description of the resident's pain (specifically verbal description of mild, moderate, severe, horrible or unable to answer) was not assessed as that section was left blank. The MDS indicated that the pain caused no difficulty sleeping or hardship with day to day activities and no pain assessment was needed for the resident. a. Care plan: The resident's comprehensive care plan was initiated on 10/2/13 and was last reviewed on 8/6/14. The care plan indicated that the resident had actual pain related to joint pain, chronic disease process, neuropathic pain, musculoskeletal pain, and chronic back and knee pain. -The care plan also indicated that the resident desired more medications than were safe to take and became angry when the physician (MD) would not prescribe. -The goals were indicated as reduction in verbalization of pain, the resident was to have increased daily function associated with decreased pain and the resident would verbalize increased satisfaction with pain control over the next 90 days. -The approaches included non-pharmacological interventions of hot/cold pack application, exercise program, recreational therapy and relaxation. The resident was to be administered [MEDICATION NAME] as ordered, a pain management flow sheet was to be implemented, and the resident was to be medicated prior to treatments and therapy. The resident was to be observed for signs and symptoms of pain, including verbal and non verbal expressions of pain every shift. -The care plan specifically indicated that the physician was to be notified if interventions were not consistently effective for pain relief. b. Pain Evaluation: The resident's most recent pain evaluation, dated 7/28/14, was reviewed. The evaluation indicated that the resident would rate his worst pain at 10/10. The resident would rate tolerable or best pain at 4/10. The resident rated his goal for pain management at 0/10. The resident described the quality of his pain as throbbing and aching. The evaluation indicated that the resident expressed his pain by verbalization of that pain. The evaluation indicated that the resident's pain was relieved by rest, positioning and pain medication administration. -The resident indicated that pain contributing factors included: repositioning, exercise/mobility and in the a.m./upon awakening. The evaluation indicated prior interventions as routine and PRN medications. The evaluation indicated that there had been no adverse consequences experienced by those medications. The evaluation further indicated continuation with the current care plan. c. Pain Management Pain Medications as ordered by the physician (MD) Review of the 9/14 computerized physician (CPO) orders, Physician Telephone Orders (PTO) and MARs dated 9/14, indicated the following current medications for pain management: -Orders initiated on 11/8/12 read in pertinent part: (Tylenol) [MEDICATION NAME]/Tylenol (a pain medication) 650 mg (milligrams) PO (by mouth), PRN q (every) 4 hr (hours). -Orders initiated on 6/1/14 indicated [MEDICATION NAME] 75mg (a controlled pain medication) tablets (tabs) PO three times a day (TID); scheduled for administration to the resident at 8:00 a.m., 1:00 p.m. and 8:00 p.m., respectively. -Orders initiated on 7/2/14 indicated [MEDICATION NAME] HCL 20 mg (a controlled pain medication) tablets (tabs) PO three times a day (TID); scheduled for administration to the resident at 8:00 a.m., 1:00 p.m. and 8:00 p.m., respectively. -Orders initiated on 8/5/14 indicated [MEDICATION NAME] HCL 10 mg (a controlled pain medication) tabs, PO TID; scheduled for administration to the resident at 8:00 a.m., 1:00 p.m. and 8:00 p.m., respectively. Physician telephone orders dated 9/8/14, indicated [MEDICATION NAME] 1% PLU (a topical controlled pain medication) 2ml (milliliters) to be applied to the left shoulder and 2mls to the right knee BID (twice a day) and PRN q (every) day, before activity to both areas. d. Physician Visit Notes: Physician visit notes dated 9/3/14, indicated that the resident had chronic pain. The MD notes indicated that the physician was unable to increase oral pain medications for the resident due to prior history of the use of [MEDICATION NAME] (medication to reverse side effects of medication that may cause increased sedation and decreased respirations symptoms), when the oral pain medications were increased. The MD visit notes indicated that the resident agreed with the trial of topical (cream) [MEDICATION NAME] for pain management. The MD notes indicated that the MD discussed the inability to increase oral medications secondary to increased sedation and decreased respirations symptoms. The resident agreed to try [MEDICATION NAME] cream (topical) to his left shoulder. e. Observations/Resident Interview: On 9/16/14 at 11:07 a.m., during the resident interview and observation portion of the survey, the resident stated he experienced unrelieved pain despite multiple assessments and treatment of [REDACTED]. -The resident stated the staff would refuse to consistently assess or address the pain and he thought the facility could do better with managing his pain. The resident stated that he experienced left shoulder pain, left hip pain associated with a history of hip replacement and he further experienced chronic left knee pain. -The resident went on to say, he had scheduled pain medications but those medications were insufficient for breakthrough pain relief. The resident further stated that staff would do nothing to help him with the break through pain. The resident stated that he was administered routine pain medications three times a day, and when he asked for breakthrough pain medications nursing staff just told him that they could do nothing. The resident stated that they had changed his pain medication regimen multiple times and it had not helped. -The resident stated that he hurt so much and he was constantly in pain and he more or less just stayed in his room all day. -During the interview, the resident stated his pain level was an 8 out of 10. At 11:44 a.m. the resident placed his call light on which was answered immediately by CNA #14. The resident asked CNA #14 to tell the nurse he was in pain and he needed pain medications. f. Subsequent observations and Interviews: On 9/16/14, the resident was observed and interviewed again at 12:30 p.m., at 1:00 p.m. and 1:20 p.m. about pain assessment and follow up. In those interviews, the resident stated the nurse had not come in to assess or address his pain. In the interview on that date at 1:00 p.m., the resident stated staff was consistently unresponsive to his complaints of pain. The resident further stated that he did not expect nursing staff to assess his pain that morning. On 9/16/14, at 1:23 p.m., CNA #14 was interviewed. In that interview, CNA #14 confirmed that she informed RN #5 of the resident's request for pain medication. On 9/16/14 at 1:25 p.m., the Unit RN #5 was interviewed about the resident's pain and treatment for [REDACTED].#5 confirmed the resident's concerns. RN #5 stated that CNA #14 told him/her of the resident's complaint of pain that morning. RN #5 stated that she/he had just medicated the resident with all his scheduled pain medications at 1:20 p.m. -RN #5 was asked about the resident's pain level at the time of his complaint (11:44 a.m). RN #5 stated that she/he did not assess the resident's pain level at 11:44 a.m. RN #5 stated the resident had no orders for any PRN pain pills but was on scheduled pain medications. -RN #5 further stated that at 11:44 a.m. he/she told the resident it was too early to give his scheduled pain medications as they were not due until 1:00 p.m. (The resident had received his scheduled pain medications and topical [MEDICATION NAME] at 8:00 a.m. that morning.) -RN #5 further stated the resident had an order for [REDACTED]. Review of the MAR and the controlled medication administration record, confirmed the resident had received the [MEDICATION NAME] topical at 8:00 a.m. RN #5 stated she administered the resident's scheduled pain medication and the [MEDICATION NAME] topical at 1:20 p.m. RN #5 confirmed she did not give the resident pain medications between 8:00 a.m. and 1:20 p.m. RN #5 stated the resident did have Tylenol PRN ordered, but she did not offer the Tylenol PRN because the resident usually refused it. RN #5 stated that she did not notify the physician, in the past or currently, when the resident refused Tylenol PRN for breakthrough pain, or that the resident experienced breakthrough pain. g. Record review: Review of the MARs dated 8/14 and 9/14 revealed no documentation of offers or refusals of Tylenol PRN. Record review also revealed there was no documentation of the resident's complaints of pain on 9/16/14 at 11:44 a.m. There also was no indication the physician was notified of the resident's reported unrelieved pain. h. Interviews: On 9/16/14 at 1:40 p.m., the findings were brought to the attention of the Director of Nurses (DON) and she was interviewed at that time. The DON stated that residents would be offered PRN medication when they had breakthrough pain. The DON agreed that the resident should have been offered Tylenol and if the resident refused (due to liver [MEDICAL CONDITION]), nursing staff was to document refusals and notify the MD. The DON further stated that if the resident experienced no relief from the PRN medication the MD was to be notified. The DON stated that her expectation was to assess and treat the resident for complaints of pain within five minutes. In another interview with the DON on 9/17/14 at 4:00 p.m., she stated that the resident should have been assessed for pain and then given any PRN medications. If there was no appropriate PRN ordered, staff should notify the MD. The DON stated that her expectation would have been to notify the MD, for input, when the resident refused Tylenol because of liver issues. On 9/17/14 at 2:45 p.m., the resident's physician was interviewed. The MD indicated that he had assessed the resident's pain management regimen multiple times. The MD acknowledged that Tylenol was contraindicated for the resident's use as he had liver disease. Furthermore, he MD stated that he was unable to increase the resident's PO pain medications as the resident had been hospitalized in the past with oversedation secondary to the use of increased doses of controlled PO pain medications. -The MD further stated that he expected nursing staff to notify the physician if the resident was not taking or refusing ordered PRN medications so the MD would be included in developing interventions for pain management. i. Further Record Review: A PTO (physician telephone order) dated 9/17/14 noted the resident could be "administered increased doses of topical [MEDICATION NAME] Cream 1% PLO 3mls to the left shoulder & 3mls to right knee twice a day & prn qd before activity to both areas." The PTO also discontinued the use of [MEDICATION NAME]/Tylenol 325 mg 2 tabs po q 4 hrs for pain as needed.

Based on record review and interviews, the facility failed to ensure one (#163) of five residents reviewed for weight loss out of 35 sample residents maintained acceptable parameters of nutritional status, such as body weight and protein levels. Specifically, the facility failed to: -Timely identify, assess and implement strategies to reverse the resident's significant unplanned weight loss; -Identify and implement effective, resident-centered approaches in order to meet his nutritional needs; and -Modify approaches when interventions were unsuccessful. These failures contributed to the resident suffering severe weight loss of 18.47 percent in 30 days. The findings included: Expectations: 1. Professional Standards According to Geriatric Nutrition: The Professionals Handbook, Third Edition, by Chernoff, pages 427-458 in pertinent part, " Many health care professionals are not attuned to the important role that nutrition plays in the maintenance of health throughout life; therefore, subclinical or marginal nutritional deficits may go unnoticed and undocumented. Malnutrition is the consequence of chronically inadequate intake of essential nutrients. [MEDICATION NAME] of normal tissue requires protein, energy, vitamins in amounts adequate to replace old cells with new ones. These elements are needed to repair damaged cells and tissues and to make substrate for protein compounds such as [MEDICATION NAME], hormones and enzymes...Body weight is one of the simplest and most routinely collected anthropometric indices used to monitor individuals and is used as a rough estimate of body energy stores...To increase the reliability and reproducibility of repeated measures, standardized procedures should be followed...Each scale should be calibrated periodically against a set of standard weights...A more clinically useful and predictive factor than relative body weight is the evaluation of changes in weight over given period of time, therefore, a careful history of previous weight gain or loss should be obtained. " In Fundamentals Of Nursing: The Art and Science of Nursing Care by Taylor, Lillis, LeMone and Lynne, Sixth Edition, page 360, "Patient records serve many purposes, such as communication with other healthcare professionals, recording of diagnostic and therapeutic orders, care planning, quality of care reviewing, research, decision analysis, education, legal documentation, reimbursement, and historical documentation. The primary purpose of the patient record is to help healthcare professionals from different disciplines (who interact with the patient at different times) communicate with one another. Communication fosters continuity of care." Facility Policy The facility policy, Weight/Hydration Management, revised 8/12 revealed in pertinent part, " As residents are weighed, staff can compare current weight to previous weight. Residents with weight variance are reweighed within 24 hours ...Weight data will be provided to the staff member designated to enter data into weight tracking program. After review of weight data, a re-weight may be requested (completed within 24 hours of request), based on resident's weight status and weight history which includes weight change of: 5% in one month (30 days); 7.5% in three months (90 days); 10% in six months (180 days). Final weight is documented in medical record on the Vital Sign and Weight Flow Sheet with the date the weight was obtained. The facility will designate a staff member to enter weight data into the medical record ...Those identified with significant weight change or insidious weight loss will be highlighted, underlined, or circled on the weight change report ...Dietary Manager and/or Registered Dietician will visit with resident, family and care staff regarding weight status and acceptable interventions ...weekly at-risk review meetings will be conducted on each resident with weight loss until the (interdisciplinary team) determines weight has stabilized and can discontinue from weekly review." 2. Resident #163 Resident #163, age 71, was admitted to the facility on [DATE]. The August 2014 admission orders [REDACTED]. The resident was also prescribed medication for constipation and pain. The 8/19/14 Minimum Data Set (MDS) revealed the resident scored 15 on his brief interview for mental status (BIMS) indicating his cognition was intact. Section F showed it was very important to the resident to have snacks available between meals. Section G reported the resident required oversight, encouragement or cueing with setup help to eat his meals. Section I reported the resident had dysphagia although no nutritional approaches were performed within seven days of the MDS evaluation. The MDS further showed the resident was 157 pounds. There was no chronic disease or condition resulting in a life expectancy of less than six months. The 8/20/14 Care Area Assessment (CAA) reported the resident left significant proportions of meals, snacks, and supplements daily for even a few days and diseases and conditions with the potential to affect the resident's appetite and nutritional needs. The listed diseases and conditions were [MEDICAL CONDITION], diabetes, and gastrointestinal problem. a. Weight History The 7/29/14 history and physical provided by the local hospital revealed the resident weighed 145 pounds. The physician reported the resident appeared well nourished with no [MEDICAL CONDITION] or tenderness. The monthly weight tracking program form was reviewed and showed the resident's 8/14 monthly weight was 157 pounds. His 9/14 monthly weight was 128 pounds. This information revealed an unplanned weight loss of 18.47% in 30 days. A review of Vital Signs and Weight Flow Sheet showed no admission weight reported on page two of the flow sheet record. There was one monthly weight listed 9/14 of 128 pounds. The monthly weight tracking form identified the resident had experienced severe, unplanned weight loss at a severity of 13.47% above the define parameters of 5% significant weight loss within 30 days. The resident's clinical record produced no evidence of approaches or interventions to monitor the resident's weight after knowledge of the unplanned weight loss. No re-weighs of any weight were identified in the resident's record. b. Interviews On 9/16/14 at 11:06 a.m., the resident was interviewed. He stated he refused to eat breakfast. He stated 97% of the morning meal consisted of sausage and scrambled eggs. He stated something more creative in the morning would be nice. The resident also expressed his meals were often brought to him cold impacting his desire to eat his meals. The resident was observed frail and malnourished wearing a hospital gown as he sat in his bed during the interview. There were multiple bony prominences on both upper and lower extremities observed. On 9/18/14 at 10:14 a.m., the registered dietician (RD) was interviewed. She acknowledged the resident had a weight loss of 18% within 30 days. She said she spoke with the director of nursing (DON) and it was determined the admission weight was inaccurate, although no evidence of re-weighs disputed the resident's weight was 157 pounds at the time of admission. The RD reported the resident had not been added to the at-risk review meetings and there were no notes in the resident's medical record to show a weekly discussion of his severe weight loss had taken place. The RD stated there was no information to show the physician had been notified of the severe weight loss and there was no information of any interventions implemented once the weights had shown an unplanned weight loss. -The RD expressed because it was reported to her the admission weight was inaccurate, she had not met with the resident to discuss his weight loss. The RD reported severe weight loss impacted the resident's healing process and muscle mass. She reported the resident's quality of life, strength, blood sugar levels, skin integrity, labs, and hydration, were all impacted with severe weight loss. The RD said based off the resident's telephone orders and medical record, he remained on a monthly weight check although 18% of unplanned weight loss was identified. The RD stated even though the resident had an 18% weight loss, he did not trigger to have interventions put in place to improve or stabilize his severe weight loss. -The RD reviewed the medical nutritional therapy review and stated she should have looked at the resident's usual body weight when the monthly weight tracking was provided. She stated a review of the resident's usual body weight would have further indicated severe weight loss of 12% in 30 days. She also discussed the concerns related to meal intake reporting and how the staff were determining the percent of meals consumed to adequate information to determine appropriate interventions. The RD stated there was no information to show the resident had been re-weighed after a 29 pound weight loss. On 9/18/14 at 11:08 a.m., the DON was interviewed. She said during admission into the facility, staff obtained weights for new residents. The DON reported residents were weighed at admission and then monthly unless otherwise noted. The DON stated the resident weighed 157 pounds according to the admission paperwork documented and could not recall anything out of the ordinary when the resident was admitted into the facility. She stated the facility policy did not follow the guideline of weighing newly admitted residents weekly for the first four weeks and monthly thereafter. The DON stated although the actual date was not listed on the resident's Vital Signs and Weight flow sheet, she said his weight was obtained on 9/1/14. She stated on 9/1/14, the resident weighed 128 pounds. -The DON acknowledged the weight loss was unplanned and significant at 18.47%. She stated when the unplanned weight loss was detected, the facility staff should have notified the RD to get in right away and assess the resident. She said there were no notes in the resident's record to indicate the physician or RD had been notified after the resident had been weighed with a weight loss of 29 pounds in 30 days. The DON stated the resident should have also been added to the at-risk review meetings because he was at-risk for weight loss. On 9/18/14 at 1:38 p.m., the RD, DON, and division director of clinical services (DDCS) were interviewed. The DDCS reported the facility could not argue weekly weights had not been started for the resident after admission or once unplanned weight loss was measured. The DDCS reported he could not dispute the resident had been identified and discussed in any of the at-risk meetings when the facility identified a weight of 128 pounds on 9/1/14 according to the DON interview above. The DDCS reported the resident's labs of pre-[MEDICATION NAME] had the appearance he was nutritionally okay which could have contributed to no implementation of nutritional interventions. The 8/26/14 pre-[MEDICATION NAME] showed the resident had a pre-[MEDICATION NAME] level of 18.9 which was on the lower end of the reference range of 17.6 - 36.0. The DDCS stated the facility should have acted upon the unplanned weight loss sooner and could not deny a lack of interventions or notification to the physician had taken place before it was brought to the facility's attention during survey. b. Resident Nutritional Assessment The 8/5/14 Medical Nutritional Therapy Review (MNTR) written by the RD revealed the resident had a usual body weight of 145 pounds. The resident had an admission weight of 157 pounds and his ideal body weight was 136 pounds. The report showed the resident had poor and/or missing dentition with mild/current diarrhea and a history of constipation. -The resident's estimated nutrition needs showed 1650-1980 calories with an estimated intake of 1150 calories; 71-85 grams of protein with an estimated intake of 45 grams. -The RD reported in a dietary note: Early satiety with decrease appetite and less than 50% meal intake. The RD documented the resident did not want supplements but was open to snacks and was encouraged to have staff ask the kitchen for snacks when desired. The RD reported weight fluctuations secondary to [MEDICAL CONDITION] and fluid retention. The goal was for the resident to eat greater than 50% of his meals. On 9/15/14, the RD added a note to the (MNTR). The note stated the weight provided to the RD for 9/14 monthly weight was 128 pounds. She noted it was 18% weight loss in one month. The RD said per the DON, the plan was to re-weigh the resident and determine if the resident had true weight decline. The RD was to follow-up with intervention if indicated weight loss seen. On 9/16/14, the RD added a note to the MNTR. She documented the DON and RD discussed the resident's admit weight was inaccurate and the resident was eating 83% of his meals with an intake of 1800 calories and 70 grams of protein. The RD changed the resident's estimated needs to 1740-2030 calories and 58-70 grams of protein. The goal remained unchanged of the resident eating greater than 50% of his meals. c. Care Plan The 8/6/14 weight loss/nutrition care plan, last reviewed by facility staff, 9/16/14 was reviewed. The facility identified the resident as a potential for weight loss/nutritional risk related to poor food/fluid intake, lab values of decreased pre-[MEDICATION NAME] and chronic diseases of diabetes mellitus type II, gout, and [MEDICAL CONDITION]. Early satiety, [MEDICAL CONDITION] and history of [MEDICAL CONDITION] with expectation of weight fluctuation secondary to liver disease and bilateral lower extremity [MEDICAL CONDITION]. The resident's usual body weight was 145 pounds and mention of admit weight being inaccurate was noted. The resident was not on any diuretic for [MEDICAL CONDITION] nor did he have a [DIAGNOSES REDACTED]. The goal of the 8/6/14 weight loss/nutrition care plan was the resident would have stable weight with 5% of his current weight. The resident's additional goal was to consume greater than 50% of meals and snacks for the next 90 days. The approaches the facility would take included: provide a regular diet as ordered, offer preferred foods, offer snacks in the evening and as needed, provide medication as ordered, provide a multivitamin as ordered, refer resident to RD and speech therapy as needed, weigh monthly or as indicated and offer snacks between meals. The care plan failed to show a weight loss of 18% and a review to determine if the approaches from 8/6/14 were effective. There was no mention of the resident being added to the at-risk review or an actual weigh loss identified within 30 days of the resident admitting into the facility. d. Meal Intakes A review of the resident's meal intakes recorded in the electronic record from 8/5/14 through 9/17/14 revealed: -There were nine dates (8/9/14; 8/10/14; 8/23/14; 8/24/14; 8/30/14; 8/31/14; 9/7/14; 9/13/14; 9/16/14) missing meal intakes for breakfast with two refusals and one incident the meal wasn't recorded because the resident was out of the facility. The meal consumptions showed out of 34 observations the resident averaged 67% of his meal intake. -There were nine dates (8/9/14; 8/10/14; 8/23/14; 8/24/14; 8/30/14; 8/31/14; 9/7/14; 9/13/14; 9/16/14) missing meal intakes for lunch with two refusals and one incident the meal was not recorded because the resident was out of the facility. The meal consumption for lunch showed out of 35 observations, the resident averaged 69% of his meal intake. -There were two dates (8/13/14; 9/4/14) missing meal intake for dinner with one refusal. The meal consumption for dinner showed out of 41 observations, the resident averaged 75% of his meal intake. -There were two dates (8/13/14; 9/4/14) missing evening snack documentation. Out of 41 observations, the resident refused his evening snack, 16 separate times. e. Conclusion & Facility Follow-up The facility failed to thoroughly assess the resident's nutritional needs due to facility communication barriers where the RD relied on the nursing staff to provide accurate meal intake and body weight information; timely notification of severe weight loss; and the implementation of person centered interventions. Subsequently, the resident was re-weighed on 9/18/14 per request of the surveyor and the RD reported the resident had further weight loss and weighed 125 pounds. The RD updated the dietary progress notes on 9/18/14. She reported according to the resident and nursing staff, the resident mostly snacked which was contradictory to the meal intake report. The RD added a nutritional supplement of med pass, 90 milliliters, twice per day for the resident and re-estimated his calorie needs between 1700-2000 calories and 60-75 grams of protein. The plan was to reweigh the resident in two weeks and the goal was for the resident to show stable weight or weight gain in the next 90 days.

Based on record review and resident and staff interviews, the facility failed to prevent pressure ulcers from developing in one of 5 sampled residents (#3). Specifically, the facility failed to properly monitor, assess, and document a developing wound which ultimately developed into a stage 4 pressure ulcer requiring hospitalization . The findings include: Facility Provided Policy on Skin Management (in pertinent part): -Residents who are at risk or with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. -Unavoidable Pressure Ulcers: ... means that the resident developed a pressure ulcer even though the facility had evaluated the resident's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. All of this must be clearly documented in the resident's clinical record. -Stage 1: the ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas, in darker skin tones, the ulcer may appear with persistent red, blue or purple hues. -Following admission, the Braden Scale for predicting pressure sore risk will be completed weekly for 3 additional weeks, quarterly, annually, and with a significant change of status for their risk for development of pressure ulcers. -Wounds are tracked as acquired and are assessed and documented on the Weekly Pressure Ulcer Record. -The Licensed Nurse will document daily monitoring of all pressure ulcers on the Treatment Administration Record (TAR). -The Licensed Nurse will record: A) plus sign + if there are no observed abnormalities or changes to the dressing, skin or pain associated with the wound. B) minus sign - if abnormalities or changes to the dressing, skin or pain associated with the wound are present/observed. If any abnormalities are observed, document a descriptive note of findings and the Licensed Nurses response in the Nurse Notes section of the resident's medical record. -Weekly Skin Check will be transcribed onto the treatment record including the day and shift on which the check will be conducted. -A Change of Condition form is to be completed and new physician's orders [REDACTED]. Resident #3, aged 58, was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum data set (MDS) completed on 5/16/2014 indicated the resident's BIM score was 15/15, indicating no cognitive impairments. The resident was total assist with activities of daily living. Medical Record Review: Physician Order: 3/24/2014- "OT (occupational therapy) re-evaluate w/c positioning/cushion due to pressure sore" Occupational Therapy: -3/18/14: "Awaiting for equipment for LE (lower extremity) positioning in w/c (wheelchair), trialed lateral support, fit not good. Issued positioning butterfly cushion to use in w/c and bed. Staff ed (education) provided. Resident still with complaints of pain." -4/8/2014: " Patient is a pleasant and cooperative male who continues to present with abnormal posture, left lateral leaning out of w/c at times per staff report " . -4/28/2014: "Patient has stage 3 decubitus ulcer on his right buttock and does not have proper cushion to prevent further skin breakdown". "OT was attempting to find proper positioning to prevent skin breakdown when patient was placed on hospice services". "Patient going to hospice care and hospice staff will take care of all his positioning needs at this point". Head to Toe Skin Checks: -February 2014 skin checks did not indicate any skin concerns on 2/6/2014 and 2/26/2014. The 2/13/2014 and 2/20/2014 checks were left blank. -March 2014 skin checks did not indicate any skin concerns on 3/6/2014, 3/20/2014 and 3/28/2014. The 3/13/2014 check was left blank. Although a physician progress notes [REDACTED]. -April 2014 skin check on 4/5/2014 indicated the right buttock was not intact, but no additional information was noted. The 4/10/2014 skin check was left blank. The 4/17/2014 skin check indicated the right buttock was not intact, but no additional information was noted. The resident was discharged to the hospital before the next skin check. -May 2014 skin checks on 5/15/2014 and 5/29/2014 documented the wound to the resident. The 5/8/2014 an 5/22/2014 skin checks were not completed. This was confirmed on the TAR (Treatment Administration Record). -June 2014 skin checks on 6/12/2014, 6/19/2014, and 6/26/2014 indicated the pressure ulcer on the resident's buttock. The skin check for 6/5/2014 was not completed. This was confirmed on the TAR. Treatment Administration Record: -March 2014-the 3/24/2014 physician order [REDACTED]. -April 2014-the 3/24/2014 physician order [REDACTED]. The dates 4/6/2014 through 4/8/2014 however, were circled but not documented if given or not. This order was discontinued on 4/8/2014. -April 2014-the 4/9/2014 physician order [REDACTED]. -April 2014-the 3/19/2014 physician order [REDACTED]. -May 2014-the 3/19/2014 order "to have abduction orthotic on in bed" was still noted on the TAR but not documented as being done or discontinued. Nurse Notes: A nurse's note on 3/26/2014 did not indicate any concerns with skin integrity. The next nurse's note was on 4/2/14, and read, "Res (resident) noted during wounds (sic) to have open area to right buttocks with dark tissue surrounding. [MEDICATION NAME] applied to area. Reported to on-coming shift, to be reported to treatment nurse". The next nurse's note was on 4/8/2014 and read, "Pt (patient) has ulcer to right buttock. RN (registered nurse) cleansed ulcer with wound cleanser, applied skin prep at wound, then applied santyl gel to wound. Covered wound with foam dressing. RN to change dressing every day. Pt denies pain". The next nurse's note was 4/17/2014 which read (in pertinent part): "Received a call from Dr. office, informed this writer about resident's schedule for cystoscopy on 22nd April 2014 at 0930. Resident needs to be there at hospital (name) at 0930 (outpatient surgery)." The next nurse's note was 4/21/2014: "Received call from hospital (name). Resident has been admitted for a wound consult and possible debridement. Nurse reports he may come back with a wound vac (vacuum). Notified his POA (power of attorney) of status". Readmission Nursing Daily Skilled Summary on 4/27/2014 revealed, "wound vac intact". Nursing Daily Skilled Summary on 4/29/2014 revealed, "resident received pain medication, providing relief". Nursing Daily Skilled Summary on 5/3/2014 revealed, "orders to d/c (discontinue) wound vac today. Hospice (name) here to speak with patient". physician progress notes [REDACTED]. A progress note on 3/24/2014 read (in pertinent part): "PU (pressure ulcer) -buttock 707.05". The next progress note on 4/23/2014 read, "Pt in hospital. No visit". The next progress note on 5/1/2014 read (in pertinent part): "Pt seen by NP (nurse practitioner) today for readmit note. Hosp 4/21-4/26. Initially for cystoscopy 4/21. Then admitted for wound consult/debridement/wound vac-PS (pressure sore) right buttock". "Wound not seen-wound vac in place". Interdisciplinary Team Meeting Notes: -The first note to document resident's skin concern was 4/10/2014: "He had a red blanchable area to right buttocks on 4/8/2014 when duoderm was removed noted an unstageable ulcer. Treatment started". -The next note on 4/17/2014 revealed, "He requires frequent dressing changes related to soiling of dressing from BM (bowel movement). He requires santyl to debride the area however have concern of how effective this may be with bid (twice daily) changes-MD is aware of this, continue with treatment as ordered". -The next note was after the resident was readmitted from the hospital, 5/1/2014: "now stage 4 ulcer with vac in place for wound. Wound has very poor color suggesting that there is poor blood circulation to the wound. Deep tissue injury was always suspected secondary to how rapidly it developed". Minimum Data Set (MDS): The MDS on 4/12/2014 indicated the resident did not have any pressure wounds, including a stage 1. The MDS on 4/24/2014 indicated the resident had 1 unstageable ulcer that was 4.8 cm (centimeters) x 4.8 cm x 0. The MDS on 5/16/2014 indicated the resident had 1 stage 4 pressure ulcer that was 6 cm x 5.4 cm x 8 cm deep. Braden Scale: A Braden Scale for predicting pressure sore risk was completed on 1/27/2014, and assessed a score of 14. This score indicated a moderate risk for pressure ulcers. There were no additional assessments made under the Braden Scale after the resident's wound was noted. Weekly Pressure Ulcer Record: -The first record was noted on 4/8/2014 as the "Date of Onset" to right buttocks. It was documented as unstageable; and 4.8 cm x 4.6 cm in diameter, moderate serosanguineous (drainage). "On 3/24/2014 the resident developed a blanchable red area to right buttocks. A thin duoderm was placed for protection. The area remained blanchable with each change until today-when nurse removed it to change and check area. Noted ulcer. Ulcer is 90% soft loose yellow slough". It read the physician, dietary, and the family were notified on 4/8/2014. -The next record was noted on 4/15/2014. The wound was measured at 4.8 cm x 4.8 cm, moderate serosanguineous, and unstageable. "Wound is not progressing as well as would like related to his loose bowel movements soiling the dressing and contaminating the wound and requiring frequent dressing changes. Change to [MEDICATION NAME] around the wound". There were no additional comments noted to indicate a need to receive debridement. -The next record was noted on 4/26/2014 upon readmission from the hospital, where wound care was provided. The wound was noted as a stage 4 with measurements of 6 cm x 5.4 cm x 5.8 cm with copious serosanguineous. "Resident had an unstageable ulcer that was being chemically debrided-he was sent out 4/21/2014 for s/p (status [REDACTED]. Currently has a wound vac". -The next record was noted on 5/5/2014. The stage 4 wound was 6 cm x 5.4 cm x 5.8 cm with undermining and copious serosanguineous. "Resident has decided to go hospice and not have wound vac anymore at this time and have only non-aggressive treatment for [REDACTED]. -The last Weekly Pressure Ulcer Record was noted on 6/17/2014 with a stage 4 measuring 6 cm x 6 cm x 6 cm with undermining and large amounts of purulent exudates. "Odor is gone-wound is unchanged at present in size. Hospice to start 6/20/2014 to do all measuring and staging". Hospital Stay Notes from 4/21/2014 through 4/26/2014 revealed: - "Right buttock wound is boggy and covered in stool at time of exam. No purulent drainage noted. The wound has necrotic material". - "(Resident) is a [AGE] year old male with a right buttock wound which has been present and worsening for the last 1-2 months. He underwent a cystoscopy and suprapubic catheter placement yesterday and he had severe right buttock pain in the PACU. He was seen by wound care who recommended that he under go debridement of the wound". - "The patient is a [AGE] year old male with MS and related complications who was admitted to the hospital from PACU for evaluation of a stage 3 decubitus ulcer of the right ischium. He had a planned outpatient suprapubic catheter placement and stone removal done on admission day and the ulcer was examined and determined he should be admitted for further care. WBC (white blood cells) was quite elevated in the 20s and his UA (urinary analysis) was of course infected appearing. General surgery was consulted and admitted the patient to the OR (operating room) for debridement of the ulcer and wound vac placement". - "CT (cat scan) reviewed and shows air, and wound in right buttock tracking into deep muscles and possibly down to bony pelvis". Hospice Initial Evaluation: -5/7/2014, "was in the hospital on [DATE] for a wound infection and debridement and for the treatment of [REDACTED]. Care Plans: -Potential for pressure ulcers related to sensory perception, moisture/incontinence, impaired mobility, nutritional/hydration risks, friction and shear problem, co-morbid conditions, and impaired diffuse or localized blood flow. Approaches (in pertinent part): apply pressure reduction mattress to bed; complete a full body check weekly and document; monitor lab values as ordered. Initiated on 9/4/2013. -Actual pressure ulcers related to sensory perception, moisture/incontinence, decreased activity, impaired mobility, nutritional/hydration risks, friction and shear problem, co-morbid conditions, impaired diffuse or localized blood flow, ms ([MEDICAL CONDITION]) in advanced stages, stage 4 right buttocks, has chosen non-aggressive treatment and hospice care. Approaches (in pertinent part): apply pressure reduction mattress to bed; reposition in chair frequently for comfort and pressure reduction; measure and stage wound weekly using the pressure ulcer healing assessment form; complete a full body check weekly and document; pressure ulcer treatment as ordered; palliative treatment care only to wound. Initiated on 5/7/2014. Facility Failures: -The facility failed to follow the care plan for the "potential for pressure ulcers" and did not complete weekly full body checks as ordered. The facility acknowledged the resident's new pressure ulcer during a care conference that was held on 4/15/2014, yet did not develop a care plan for a developed pressure ulcer until over a month after the wound developed. -The MDS coded on 4/12/2014 did not acknowledge the open area on the resident's right buttock, although nurse's notes confirmed its presence on 4/2/2014. - The physician noted the resident had a pressure ulcer to his buttock on the progress note of 3/24/2014, yet there was no further evaluation noted on the physician record until after the resident returned from the hospital with a wound vac. -The first nurse's note indicating a wound on the resident's right buttock was not until 4/2/2014; 6 days after the physician noted it in his progress notes. -The first pressure ulcer recorded for wound change was done on 4/8/2014 and indicated the wound was not developed until that time, which conflicts with the physician progress notes [REDACTED]. -The IDT meeting on 5/1/2014 indicated that a deep tissue injury had been suspected, but no documentation prior to the resident's hospitalization indicated any attempt to assess resident regarding this concern. The hospital analysis indicated the resident's pressure wound appeared to have been developing over a period of 1-2 months, yet the IDT meeting notes indicated they felt it was quickly developed. -The wound care nurse stated the resident's wound vac was ordered and used after she placed the order, yet notes indicated the resident returned from the hospital with it already intact. Interviews: An interview with a certified nursing aide #1 (CNA) on 7/3/2014 at 10:10 a.m. revealed the CNA could not recall when resident #3 developed his skin problems, and stated, "it might have been from his wheelchair". The CNA stated the resident only wore the hip orthotic for a short time. The CNA said the resident had been looked at by the occupational therapy department just prior to going onto hospice. The CNA stated the aides were responsible for looking carefully at resident's skin during showers, and if they saw anything they were supposed to tell the nurses who were required to document it. An interview with the Director of Nursing #2 (DON) on 7/3/2014 at 10:35 a.m. confirmed that the aides were required to do a visual skin check of the residents and then let the nurses know. The DON stated the nurses were responsible for documenting any skin conditions. An interview on 7/3/2014 at 10:40 a.m. was conducted with the licensed practical nurse #3 (LPN)/wound nurse. The wound nurse stated the resident developed a red blanchable area on 3/24/2014, but was only picked up for wound care on 4/8/2014, once it became ulcerated. This nurse stated on 6/17/2014 it was decided it was too difficult for 2 individuals to measure wounds, so hospice took over his wound care on 6/20/2014. The LPN stated the resident had gone out to the hospital because he was having problems with his suprapubic catheter, but ended up staying due to debridement of his wound. The wound nurse said they had been doing chemical debridement, but the hospital did it surgically. This wound nurse stated she had initiated the wound vac use when he came back from the hospital, and that the hospital had not done it. She stated she put the order in on 4/29/2014. She also stated that once the resident went on to hospice, the wound vac was discontinued and the wound was packed. The wound nurse stated she felt the wound care should have been more aggressively handled, because he probably had a deep tissue injury. She stated she could only speculate as an LPN that it was a deep tissue injury; because of the "scarlet coloring," and because he was having tubes put in and taken out. The wound nurse stated she had asked the physician to look at the resident's wound when she was caring for it. However, the resident was sent to the hospital only for catheter care. She said the hospital called the facility about the resident's wound while providing catheter care, and asked the resident's physician to contact the hospital. The LPN stated the physician agreed to the plan for hospital debridement. An interview with the DON #2 on 7/3/2014 at 10:45 a.m. revealed, the resident was sent out to the hospital for his suprapubic issues only, and not for his wound. She stated the hospital contacted the facility with "concern about the wound ". She stated the hospital physicians were even concerned regarding what the resident was sleeping on, and they came to agreement that the resident should be provided a Dolphin mattress. The DON confirmed that they told the resident's physician he should have written the orders better for the resident's care. The DON stated when the resident went on to hospice, she noticed the resident's new Dolphin mattress was removed, without her consent. The DON confirmed that the resident had not wanted to be on hospice until his wounds became bad. An interview was conducted on 7/3/2014 at 12:38 p.m. with the physical therapy manager #4 (PT) regarding resident #3's wound. The PT stated they had looked at the resident from January 2014 through March 2014 for wheelchair positioning. The PT stated that the facility "came to us on 4/8/2014 because they thought he was breaking down". The PT staff member stated they reevaluated the resident and decided he needed an air cushion for his wheelchair, so they ordered it. The PT stated that before the cushion could come in, the resident was sent out to the hospital on [DATE]. "We only knew from the 8th that he needed looked at" and that "we didn't know too much about the hospital stay". The PT stated the resident had been wearing the hip orthotic to improve his tone while he was up in the chair, but didn't use it too long because of his change in condition. An interview was conducted with a registered nurse #5 (RN) on 7/3/2014 at 1:07 p.m. about proper skin documentation. The RN stated the skin sheets had always been in the MAR for the nurses to document as ordered. The RN stated the MAR indicated [REDACTED]. She confirmed that not all of the MARS appeared to have been filled out correctly under skin checks. An interview was conducted resident #3 on 7/3/2014 at 1:33 p.m. The resident stated he recently received a new wheelchair because the other one wasn't good for him. The resident stated that he wasn't sure how his pressure ulcer developed so quickly, and it surprised him. He stated it was the doctors in the hospital who told him about the wound and then treated it. He stated he thought his wheelchair wasn't comfortable enough before, and that maybe he wasn't sitting in it right. The resident stated he felt like they should have done something sooner to prevent the wound from developing. An interview was conducted with the DON and the nursing home administrator #6(NHA) on 7/3/2014 at 2:30 p.m. regarding the resident's wound. The NHA stated the resident went to the hospital only because it was a scheduled appointment, and that the physician had not requested the resident be sent for wound care or evaluation. The NHA and DON both expressed gratitude the hospital physicians had noted the wound and offered to provide wound care for the resident.

Based on observations, interviews and record review, the facility failed to ensure one of 17 sample residents (#15) with a pressure ulcer, received the necessary treatment and services to promote healing and prevent infection. Specifically: The facility failed to assess, monitor, and ensure care planned interventions were implemented to promote healing of resident #15's Stage II coccyx pressure ulcer. The physician was not notified, consulted, or asked to observe the wound, even as the ulcer progressed to "unstageable" and enlarged. The resident was hospitalized with a Stage IV ulcer. The findings include: A. Facility Policy The facility's Skin Management policy, dated 2010, included the following definitions and practice guidelines: -"Upon admission, all residents are assessed for skin integrity by completing a head to toe physical assessment of skin condition and completing the Braden Scale-For Predicting Pressure Sore Risk. Following admission, the Braden Scale will be completed weekly for three additional weeks (for a total of four weeks including admission), quarterly, annually, and with a significant change of status for their risk for development of pressure ulcers... -The care plan should address, but is not limited to: hydration, nutrition, preventive devices, positioning requirements, and proper body alignment... -Ongoing monitoring and continuous quality improvement will be achieved by the Interdisciplinary (IDT) Team; Care Management Risk Review Meetings will be conducted weekly to review/discuss: new admissions, residents identified at risk or with compromise, resident with any skin changes, treatment modalities and interventions with resident/family, and recommendations based on interdisciplinary evaluation...The assigned IDT member will ensure communication to other staff of the results of the review and any changes to the Plan of Care..." The Skin Management policy included the following Staging Classifications definitions: -"Stage II - Partial thickness of skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as abrasion, blister, or shallow crater; -Stage III - Full thickness of skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue; -Stage IV - Full thickness loss of skin with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures; -Unstageable - When eschar is present, accurate staging is not possible until the eschar has sloughed or the wound has been debrided. Document as eschar covered area, "unable to determine" depth and stage, etc. Eschar in the wound bed may be tan, brown, or black in color. Unstageable wounds may be covered by yellow, tan, gray, green, or brown slough." B. Resident #15 Resident #15 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 3/2/12, indicated the resident had moderate cognitive impairment, and required a 2-person assist for bed mobility, transferring, dressing, toileting, and personal hygiene. The MDS assessment further indicated the resident had a pressure ulcer which measured 2.7 cm (centimeters) x 2.0 cm, with necrotic tissue (eschar). 1. Knowledge of Resident's Risk Review of resident #15's record revealed a Braden Scale form and indicated two assessments dates: 11/14/11 (admission), with a score of 10; and 3/2/12 (quarterly), with a score of 13. According to the form, a score of 12 or less represented high pressure sore risk, 13-14 moderate risk, and 15-18 mild risk. There was no evidence that four weekly assessments were completed initially per facility policy. According to the 3/7/12 physician's progress notes, the resident had a stage II ulceration to coccyx, approximately quarter-sized with bruised discoloration interspersed with normal skin color, trace serous drainage noted. Under diagnostics, radiology studies from 12/20/11 showed positive inflammation, infection,[MEDICAL CONDITION] of coccyx wound, plus possible osteo[DIAGNOSES REDACTED] of coccyx. The notes documented the resident was at risk for delayed wound healing due to debilitated state and need to keep head of the bed elevated at least 30-45 degrees at all times to prevent aspiration, thus putting increased pressure on coccyx. 2. Worsening of Coccyx Wound Review of the Weekly Pressure Ulcer Record completed by the facility's wound care nurse revealed documentation the resident's coccyx wound declined from a Stage II wound (see above) to "unstageable" and increased in size. Specifically: -3/20/12 - Unstageable; 4.5 cm x 2.8 cm; no depth; no undermining; small amount of serosanguinous exudate with no odor; wound bed brown/yellowish - wound edges bright red; surrounding skin color normal. -3/27/12 - Unstageable; 5.4 cm x 5.4 cm; 0 depth; no undermining; small amount of serosanguinous exudate with no odor; wound bed red; surrounding skin color bright red. -4/3/12 - Unstageable; 6.6 cm x 3.9 cm; 0 depth; no undermining; small amount of serosanguinous exudate with no odor; wound bed red; surrounding skin color dark red. -4/10/12 - Unstageable; 6.0 cm x 5.0 cm; 0 depth; no "visible" undermining; small amount of exudate with no odor; wound bed 90% grayish and yellowish and 10% dark red; surrounding skin color dark red. -4/17/12 - Unstageable; 6.3 cm x 3.8 cm; 0 depth; no "visible" undermining; small amount of serosanguinous exudate with no odor wound bed ("no significant change from previous week"); surrounding skin color dark red. This was the last entry in the Weekly Pressure Ulcer Record, as the wound care nurse resigned on 4/20/12. The depth of the wound for each of these dates was documented as "0"; however, according to the facility's policy, depth should have been documented as "unable to determine" for an unstageable pressure ulcer. The resident's record also included weekly interdisciplinary (IDT) notes, in which the status of the resident's coccyx pressure ulcer was addressed. However, there were no IDT entries after 3/27/12. 3. Facility Response to Worsening Ulcer The resident's recapitulation orders for April 2012, pertaining to the coccyx pressure ulcer, included a treatment order (using a wound cleanser, santyl ointment, and an [MEDICATION NAME] covering), an order to reposition the resident every two hours every shift, an order for [REDACTED]. 4. Failures in Facility's Response a. Record Review See above; there was no documentation that showed the resident's wound was assessed and monitored by the IDT committee after 3/27/12 and by the wound nurse after 4/17/12. Review of the Weekly Pressure Ulcer Reports above, as well as the IDT committee notes, revealed no documentation the physician was notified or consulted, or asked to observe the resident's wound by either the wound care nurse or the IDT committee that resident #15's pressure ulcer had progressed from a Stage II wound to an unstageable wound. Review of the April TAR indicated the resident was out of bed twice each day for 11 out of 30 days in April, contrary to the orders above. (See interviews below and F353 for further details on insufficient staff to meet resident needs.) Review of the TAR documented the resident was repositioned every shift; however, there was no documentation that showed the repositioning occurred every two hours as ordered. (See interviews below and F353 for further detail on insufficient staff to meet resident needs.) Review of the resident's Pressure Ulcer care plan revealed it did not include the order, or approach, to be out of bed twice daily, nor did it specify how often the resident was to be repositioned. The wound care nurse's last entry to the care plan was dated 4/17/12. b. Staff Interview and Staff Record Review On 5/2/12 at 1:00 p.m., the nursing home administrator (NHA) was interviewed. The NHA explained that resident #15's wound status was supposed to be reviewed weekly by the IDT team. The NHA confirmed that there was no evidence the IDT team was involved in evaluating the progress of the coccyx pressure ulcer and reviewing the plan of care after 3/27/12. On 5/3/12 at 2:00 p.m., the previous wound nurse's file was reviewed. The file revealed the wound nurse was licensed as a practical nurse (LPN) back in 1978. The LPN listed that she had two years of experience with wound care. However, there was no documentation found to show the LPN had taken or received any wound care training. 5. Resident #15's hospitalization [DATE]-[DATE] On 5/2/12 at 12:30 p.m., the charge nurse reported she accompanied the physician on wound rounds on 4/25/12, because the wound care nurse was no longer working in the facility. The nurse stated, "We were taken aback at how drastically it (the pressure ulcer) had changed. There was tunneling." On 4/25/12, the physician wrote an order for [REDACTED]. From the WCC, the resident was transferred to the hospital. According to the hospital transcription report, dated 5/1/12, the resident presented with a large decubitus, full-thickness Stage IV. The report read, in pertinent part: -"(Resident #15) presents to the emergency room with a chief complaint of sacral decubitus ulcer...The coccyx ulcer that they have been utilizing various treatments on has been an ongoing problem for years; however, now it has become full-thickness and more severe. -The patient is very deconditoned...The patient does have a large decubitus ulcer, full-thickness, stage IV that measures 70 mm (millimeters) in length, 65 mm in width, 22 mm in depth to the bone. There is a small amount of pink granulation tissue built up within the wound. A large quantity of eschar with necrosis and foul odor. There is a large amount of drainage from the wound, yellow-green serosanguinous." The report went on to describe how the emergency room physician debrided the resident's coccyx wound. -"I have advised absolute offloading with every 2 hour rotation, wet-to-dry dressing changes daily until the wound vac can be put into place. I have stressed the importance of offloading..." The resident was transferred back to the facility on [DATE]. 6. Status After Re-admission - Hospital Re-admission 5/2/12 On 5/1/12, resident #15 was observed to remain in her bed throughout the day. On 5/2/12 at 11:30 a.m., resident #15's family member was interviewed. The family said the resident was sent out to the wound clinic recently and then on to the hospital. She returned to the facility "just yesterday." S/he said the family was not comfortable with the lack of care for the resident and the progressing wound she had. On 5/2/12 at 11:45 a.m., another family member of resident #15 was interviewed. The family stated the resident started out with a stage I pressure sore, that progressed to a stage IV. They said the facility no longer had a wound nurse, so the resident's wound was not followed as it should be. The family stated the resident (currently) had a temperature up to 104 degrees and they felt she should be hospitalized . They said the facility was "pushing Tylenol and pain medication to get the resident's temperature down." On 5/2/12 at 11:50 a.m., nurse #6 was interviewed. The nurse stated the resident was "still running a temp over 103 degrees." She said the resident's physician was in earlier to see the resident and ordered injectable antibiotics, a urinalysis and requested that all diagnostic studies from the hospital be faxed to him. The nurse confirmed the resident just returned from the hospital 5/1/12, "with no significant findings." According to the nurse, no hospital documentation or orders accompanied the resident initially, so the staff did not know what was done for the resident. Nurse #6 stated, "They should have sent documentation with her." The resident was transferred back to the hospital the afternoon of 5/2/12 and had not returned to the facility during the remainder of the survey. 7. Cross-reference F353; Insufficient Staff to Meet Residents' Needs On 5/1/12 at 3:35 p.m., certified nurse aides (CNA) #1 and #2 were interviewed. -Both stated they each were assigned 12 residents to care for. They said there used to be two CNAs per hall, however, assignments were changed and each CNA was split between 2 halls. They reported, "Sometimes we may have 18 residents on a shift." They said a typical assignment was two CNAs for 23 residents in addition to each one being responsible for 2-3 showers on the shift. -Both said that residents complained about lengthy wait times for call lights. CNA #1 said, "We can't get to the residents all at one time. We do run late because we are so busy, we can't get to them." -Both further stated they were not able to get to all the residents timely. They said as a result, they were late in getting to the residents that needed to be turned every two hours. (Cross Reference F353 Sufficient Staffing) On 5/2/12 at 10:00 a.m., nurse #4 was interviewed. She stated that two CNAs were split between two halls, and then if needed, one of the CNAs would be pulled to accompany a resident who had an outside appointment, therefore, leaving only one CNA to cover. She stated there were some residents who required two people for provision of care. "You need to find help, that takes time, if the other aide is in bathing someone; plus we can't get our medications passed on time because we are helping the aides." On 5/2/12 at 10:50 a.m., nurse #5 was interviewed. -The nurse said the staffing was "terrible, the care is compromised because of staff. The previous staff truly cared and were attentive. We run around doing a million things; spending more time in the dining room, (we) have MDS (Minimum Data Set) assessment duties and SS (social service) duties. Residents are stressed and miserable." -The nurse said, "Nursing staff are bounced all over, leaving residents confused and stressed. We have charge nurses, however, they are doing administrative stuff, so that doesn't help with the care." The nurse said, "I had one resident who cried, thinking staff didn't like her because no one ever came around." -The nurse said the secured unit was covered by the nurse who also had multiple rooms on the 400 hall. Therefore, the CNA would sometimes be on the unit alone for hours at a time. In addition, nurse #5 further stated the facility was minus an assistant director of nursing - ADON (the current DON was out of the facility at the time of the survey), an MDS coordinator, wound nurse and social services (SS).

Based on record review and staff interview, the facility failed to ensure one of 37 sample residents (#113) received proper respiratory treatment and care. Specifically: Resident #113 had a history of [REDACTED]. Facility staff failed to promptly respond to the resident's respiratory distress, evidenced by complaints of severe shortness of breath (SOB), elevated pulse and respiratory rate, and low oxygen saturation levels. Facility staff's failure to promptly respond contributed to the resident experiencing prolonged symptoms of respiratory distress. The findings include: A. References According to "Clinical Nursing Skills & Techniques," by Perry & Potter, 5th Edition, (2004), pages 250-251: "Pulse oximetry (ox) is the noninvasive measurement of arterial blood oxygen saturation - the percent to which hemoglobin is filled with oxygen. . . An oxygen saturation between 90% and 100% indicates adequate oxygenation. . ." According to "Medical Surgical Nursing," by Lewis & Collier, 3rd Edition, pages 445 and 814: "The SaO2 is expressed as a percentage. . .A SaO2 at 88% is adequate for clients with chronic hypoxemia. . . a SaO2 < 75% is inadequate; tissue [MEDICAL CONDITION] (refers to a deficiency in tissue oxygenation and is associated with symptoms that reflect inadequate oxygen delivery to vital organs, such as the heart and brain) and cardiac [MEDICAL CONDITION] (irregular heart beat) can be expected." B. Resident Failure Resident #113, [AGE] years old, was admitted to the facility, on 2/11/11. According to the facility face sheet, the resident's [DIAGNOSES REDACTED]. 1. Resident Status According to the minimum data sets (MDS), dated [DATE], the resident's BIMS (brief interview for mental status) score was 15 (cognitively intact) and oxygen treatment was used prior to and after admission to the facility. On 4/18/11 at 5:45 p.m., resident #113 and his daughter were interviewed. Both indicated that the resident had severe [MEDICAL CONDITION] and anxiety related to that diagnosis. According to the computerized physician orders [REDACTED]. The start date for the order was 2/16/11. 2. Respiratory Distress 4/21/11 According to the nursing daily skilled summary dated 4/21/11: -at 5:00 a.m., the writer was called to the resident's room, resident had complaint of severe shortness of breath (SOB), oxygen at 5 liters, pulse oximetry (pulse ox) 60-80%, resident requesting air, respiratory treatment given, breathing has not improved, encouraged to take slow deep breaths in/out. -at 5:30 a.m., resident complaint of back pain gave 2 narco 5/325 mg per order as requested. Pulse ox 70%, blood pressure 130/80, pulse 115, respirations 30, and temperature 97.3, gave symbocort 2 puffs. Resident trying to take breaths in/out. -at 5:45 a.m., resident's pulse ox dropping. Dr. (name) called, states can send to (hospital) for evaluation. 911 called at 5:50 a.m., resident continues to have severe SOB, alert, talking some. AMR notify for transport at 5:55 a.m., -at 6:00 to (hospital) for evaluation. -at 7:25 a.m., daughter called facility and aware. -Late entry 5:30 a.m., oxygen increased to 10 liters, resident complaint of not being able to breathe, severe SOB with no improvement noted or voiced. On 4/26/11 the licensed practical nurse (LPN) responsible for caring for the residents residing on resident #113's hall indicated that the resident was in the hospital in the intensive care unit (ICU) and he was intubated. She indicated that he had an episode of respiratory distress and was sent out to the hospital. 3. Failures in Facility Response to Resident's Respiratory Distress a. Record Review There was no documentation that indicated that the resident was assessed by a registered nurse (RN), from 5:00 a.m. to 6:00 a.m., when the resident was transferred to the hospital. All entries above, on 4/21/11, were signed by the same licensed practical nurse (LPN). b. Staff Interview On 4/28/11 at 1:15 p.m., the director of nursing (DON) was interviewed. -The DON indicated that she was unaware of the actual events leading up to the resident's transport to the emergency room . She requested that the chart be brought to her office. -The DON, after reviewing the record, said that based on the order to notify the physician if the resident's pulse oximetry was below 90%, her expectation would be that the nurses immediately notify the physician. She indicated that the only reason to delay the notification would be to make the resident as safe as possible prior to the call. -The DON said there is a RN supervisor in the facility at all times and the expectation is that the RN is notified whenever there is an acute situation/episode. The DON agreed that there was a delay in necessary treatment for [REDACTED]. -The DON confirmed that the resident was in the hospital in the ICU (intensive care) and that he was intubated. She was unsure of his condition beyond that.