Every finding on record at Hearthstone Nursing & Rehabilitation Center

Based on interview and record review it was determined the facility failed to ensure residents received required admissions documents at or before admission for 1 of 3 sampled residents (#9) reviewed for resident rights. This placed residents at risk for not understanding their rights and services. Findings include:Resident 9 was admitted to the facility in 10/2025 with diagnoses including diverticulosis (small pouches in the colon) and cognitive communication deficit (trouble understanding or expressing speech). A certified mail receipt dated 2/6/26 with a handwritten note revealed the admissions packet was generated on 10/30/25 and discovered it was not signed. The packed was sent via certified mail to Resident 9. On 2/23/26 at 2:02 PM, Witness 19 (Family Member) confirmed Resident 9 did not receive her/his admission documents until after she discharged from the facility, and she/he received by certified mail. On 3/4/26 at 10:37 AM, Staff 27 (Admissions Director) stated he noticed some residents did not receive their admissions documents upon admission to the facility. Staff 27 sent them in the mail to the residents who had not received. Staff 27 stated a lot of staff had been in the position and some were terminated and some quit. On 3/4/26 at 11:58 AM, Staff 2 (DNS) stated she expected staff to provide residents their admission documents timely.

Based on interview and record review, it was determined the facility failed to ensure residents were free from misappropriation of money for 1 of 4 sampled residents (#18) reviewed for abuse and misappropriation. This placed residents at risk for loss of property. Findings include:Resident 18 was admitted to the facility in 10/2025 with diagnoses including anxiety and depression. An admission MDS dated [DATE] indicated Resident 18 was cognitively intact. On 1/23/26, the State Survey agency received a public complaint which indicated on 1/19/26, Witness 17 (Complainant) reviewed Resident 18's bank statement and found multiple charges on her/his card from 12/4/25 through 12/25/25. Resident 18 had not used her/his card and believed staff, or a visitor used the card. The total was $1,696.00 in charges. A police report was filed, but he had not reported it to the facility. A facility investigation completed on 2/20/26 indicated on 2/14/26 at approximately 5:00 PM officers from the police department arrived at the facility and showed a photograph of Staff 25 (CNA/Receptionist). The police reported bank card charges totaling approximately $1,700 in unknown purchases which started in 12/2025. The purchases were described as household goods and toys. Resident 18's bank card was in her/his billfold in her/his room. Staff 25 reported to the facility she used $100 for her personal use, and her intent was to pay the resident back. Misappropriation of funds was identified with Staff 25 acknowledging use of the bank card. On 2/24/26 at 9:10 AM, Witness 17 stated there was pictures of the Staff 25 making purchases in the store. On 2/25/26 at 11:17 AM, Resident 18 stated she did not authorize the purchases. Resident 18 stated she currently felt safe in the facility and the police saw pictures of the person who took her/his money. On 3/3/26 at 10:05 AM, Staff 25 stated Resident 18 kept requesting snacks and kept crying and begging for someone to get them for her/him. Staff 25 stated she regretted using Resident 18's card and stated Resident 18 was like family and borrowing money from family. On 3/4/26 at 12:07 PM, Staff 1 (Administrator) and Staff 2 (DNS) stated they would expect staff not to use a resident's bank card. The deficient practice was identified as Past Noncompliance based on the following: On 2/16/26, the deficient practice was identified by the facility and was corrected when the facility completed an investigation and identified system failures in the identification of misappropriation. The Plan of Correction included: -Staff 25 was terminated and reported to OSBN. -Resident 18 would be monitored for negative psychosocial impact. -Baseline interview audit of residents and/or resident family members to ensure there are no additional resident who have experienced misappropriation of funds by a staff member. -Education to current active staff regarding misappropriation. -Monitoring conducted weekly for four weeks, then monthly for two months. -Audit trends to be reported to the facility QAPI for three months for review and further recommendations. -Resident council meeting was conducted to review resident rights to have personal belongings maintained safely within the facility and options for storage.

Based on interview and record review, it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 3 of 5 sampled residents (#s 3, 6, and 13) reviewed for ADLs and call lights. This placed resident at risk for unmet needs. Findings include:1. Resident 3 was admitted to the facility in 6/2025 with diagnoses including muscle weakness and adult failure to thrive. A 6/30/25 admission MDS indicated Resident 3 had moderate cognitive impairment and was dependent on staff for showers. The 8/2025 Documentation Survey Report (CNA task report) indicated Resident 3 did not receive any type of bathing from 8/10/25 through 8/19/25 (10 days). On 8/13/25 and 8/16/25 the documentation indicated NA. On 3/3/26 at 9:07 AM, Staff 17 (CNA) stated she would document NA when she did not have time to provide a shower for a resident in 8/2025. On 3/3/26 at 9:40 AM, Staff 18 (CNA) stated there were times in 8/2025 showers were not offered to residents.On 3/4/26 at 11:51 AM, Staff 2 (DNS) stated she would expect residents to receive their scheduled showers. 2. Resident 6 was admitted to the facility in 12/2024 with diagnoses including chronic kidney disease and urinary tract infection. A 7/3/25 Quarterly MDS indicated Resident 6 was cognitively intact and was dependent on staff for toileting transfer and hygiene. Resident 6 was occasionally incontinent of bladder. On 2/27/25 at 8:00 AM, Resident 6 stated at times she/he had to wait up to an hour to have staff assist with toileting. Resident 6 stated when she/he had to wait a long time she/he would hurt and had to urinate really bad. Resident 6 stated the daytime was the worst for long waits. On 3/3/26 at 9:58 AM, Staff 25 (Former CNA) stated she has observed Resident 6 have an incontinent episode from having to wait a long time. On 3/3/26 at 2:30 PM, Staff 29 (CNA) stated she had seen Resident 6's call light on, and the resident would tell her she/he was waiting to use the toilet. Staff 29 stated she would apologize when she could not met residents' care needs. On 3/4/26 at 10:21 AM, Staff 41 (CNA) stated she had observed Resident 6 have an incontinent episode from having to wait too long for assistance with toileting. On 3/4/26 at 11:53 AM, Staff 2 (DNS) stated she would expect staff to assist so Resident 6 would not have incontinent episodes. 3. Resident 13 was admitted to the facility in 6/2025 with diagnoses including muscle weakness and a need for assistance with personal care. A 6/30/25 admission MDS indicated Resident 13 required partial to moderate assistance of one staff with bathing. A 7/10/25 Care Plan documented Resident 13 required substantial to maximal assistance of one staff with bathing. The 11/2025 Documentation Survey Report revealed Resident 13 was scheduled for bathing on Tuesday and Saturday evenings. The report indicated Resident 13 received bathing four times in 11/2025, and no bathing from 11/12/25 through 11/21/25 (10 days). On 12/11/25 the State Survey agency received a complaint indicating Resident 13 was not receiving bathing. On 3/3/26 at 3:01 PM, Staff 58 (Agency CNA) stated she did not remember Resident 13 refusing bathing in 11/2025 and stated at times could not complete resident's bathing. On 3/4/26 at 11:51 AM, Staff 2 (DNS) stated she would expect residents to receive their scheduled showers.

Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 4 sampled residents (#19) reviewed for medications. This placed residents at risk for delayed treatment and unmet medication needs. Findings include:Resident 19 was admitted to the facility in 12/2025 with diagnoses including chronic pain and sepsis.A 12/2025 MAR instructed staff to administer the following medications on 12/31/25:-Linezolid (an antibiotic medication) for sepsis; referred the reader to Administration Notes-Oxcarbazepine (an anticonvulsant medication) for convulsions; referred the reader to Administration Notes -Gabapentin (an anticonvulsant medication) for pain; referred the reader to administration notes.Administration Notes dated 12/31/25 revealed the following medications were on order from the pharmacy:-Linezolid for sepsis-Oxcarbazepine for convulsions-Gabapentin for painOn 2/4/26 the State Survey agency received a complaint indicating Resident 19 missed physician-ordered medications. On 3/3/26 at 12:38 PM, Staff 22 (CMA) stated Resident 19 was sent to the hospital and when she/he returned someone had destroyed all her/his medications. Staff 22 stated the resident was not gone long and the situation was frustrating due to the resident did not receive her/his medications. On 3/4/26 at 12:05 PM, Staff 2 (DNS) stated she would expect staff to communicate with pharmacy and have no lapse in resident medication.

Based on interview and record review it was determined the facility failed to ensure resident records were complete and accurate for 3 of 14 sampled residents (#s 1, 4, and 12) reviewed for medical records. This placed residents at risk for inaccurate medical records. Findings include:1. Resident 1 was admitted to the facility in 1/2025 with diagnoses including diabetes. Resident 1's 12/2025 DAR (Diabetic Administration Record) indicated for staff to administer insulin before meals. The 5:30 PM administration time, had 4 out of 31 instances where no documentation to indicate if Resident 1 refused or was administered their insulin. The 5:00 PM administration time had 4 out of 31 instances with no documentation on the DAR and the 8:00 PM administration had 1 of 31 instances where no documentation was indicated for insulin administration. On 3/4/26 at 10:06 AM, Staff 28 (LPN) stated Resident 1 would refuse and ask for insulin later, and when offered later, she/he would refuse again. Staff 28 stated she forgot to document the resident's refusal on the DAR. On 3/4/26 at 11:46 AM, Staff 2 (DNS) stated the expectation of staff was to document residents' refusals on the DAR. 2. Resident 4 was admitted to the facility in 1/2025 with diagnoses including traumatic brain injury and dementia. A 6/10/25 Quarterly MDS indicated Resident 4 was rarely understood and dependent on staff for eating. A care plan revised on 12/12/24 revealed Resident 4 was totally dependent on one staff for eating. A Documentation Survey Report for 8/2025 revealed out of 124 opportunities, staff documented Resident 4 as independent with eating on ten occasions and requiring setup or clean-up assistance on four occasions. On 3/3/26 at 9:52 AM, Staff 25 (CNA) stated she should not have documented Resident 4's eating assistance as independent, since she/he always had been dependent and required staff support with eating. On 3/4/26 at 11:52 AM, Staff 2 (DNS) stated she expected staff to provide accurate documentation of residents' eating assistance requirements. 3. Resident 12 was admitted to the facility in 10/2025 with diagnoses including muscle weakness, lack of coordination, and Alzheimer's disease. A 10/7/25 admission MDS indicated Resident 12 had significant cognitive issues and required substantial to maximal assistance from staff for dressing. A care plan dated 10/15/25 revealed Resident 12 required substantial to maximal assistance of one staff for lower-body dressing. A Documentation Survey Report for 11/2025 revealed out of 61 opportunities, staff documented Resident 12 as independent with lower body dressing on three occasions. On 3/3/26 at 9:45 AM, Staff 18 (CNA) stated the charting use to be weird and unclear on what to document. Staff 18 stated she probably missed documenting Resident 12's lower body dressing abilities. On 3/4/26 at 11:52 AM, Staff 2 (DNS) stated she expected staff to provide accurate documentation of residents' dressing abilities.

Based on interview and record review it was determined the facility failed to revise care plan interventions and re-evaluate a resident's elopement to ensure a resident's safety for 1 of 3 sampled residents (#1) reviewed for elopement. This placed residents at risk for repeated elopements. Findings include:Resident 1 admitted to the facility in 8/2025, with diagnosis including squamas cell cancer to the face, psychosis, delusional disorder and schizophrenia.Resident 1's profile page revealed Resident 1 had a guardian.On [DATE] Resident 1 was granted a guardian. The resident's guardianship paperwork included separate numbers for communication involving everyday contact through emergency contact.Resident 1's [DATE] admission MDS revealed she/he was independent with mobility; however she/he had impaired strength, balance and endurance that limited safe participation in daily routines.Resident 1's [DATE] Progress Note indicated she/he left the facility and a voice message was left for her/his guardian.Hospital Records dated [DATE] revealed Resident 1 was admitted to the hospital on [DATE] after being found wandering in the streets with a maggot infestation to her/his face and indicated Resident 1 had cognitive decline with suspected vascular dementia. The resident returned to the facility on [DATE].Resident 1's [DATE] Care Plan indicated she/he was a low elopement risk and was at risk for falls related to impaired mobility due to vision impairment. Resident 1's care plan did not include the resident's elopement on [DATE], and no interventions were developed to ensure the resident's safety. Resident 1's [DATE] Progress Notes revealed she/he wanted to leave the facility. Both Staff 7 (Nurse) and Staff 3 (LPN, Assistant DON) attempted to educate the resident on her/his choice to leave the facility. Staff 3 observed Resident 1 leave the facility and get on a city bus. A voice message was left for Resident 1's guardian.A [DATE] Progress Note indicated Staff 3 was interviewed by a local law enforcement officer (LEO). Staff 3 informed the LEO the resident was alert and oriented, had the right to leave, the resident had signed the AMA form, education was given to the resident, and the guardian was notified.Resident 1's [DATE] Hospital Records indicated she/he was brought to the hospital after she/he left the facility two days prior. Bystanders were concerned for Resident 1 and had called 911. The records indicated the resident did not have decision making capability and it was inappropriate to allow Resident 1 to leave or sign out of the nursing facility.The facility did not complete an investigation for the [DATE] or [DATE] elopements.On [DATE] at 12:22 PM, Witness 1 (Guardian) verified Resident 1 eloped twice since her/his admission to the facility and stated both times she was not contacted on her emergency line, but instead, the facility left a voice message on her main telephone number. Witness 1 stated she had provided the facility with the guardianship papers with directions on how to contact her on two separate occasions and explained the resident did not have the capacity to make the decision to leave AMA (against medical advice).On [DATE] at 3:21 PM, Staff 8 (Former LPN) indicated she was not aware Resident 1 had a guardian. Staff 8 stated she worked alongside Staff 7 (RN), who was the AMA specialist when Resident 1 left AMA on [DATE]. Staff 8 stated she did not know why Resident 1 was allowed to leave the facility.On [DATE] at approximately 3:30 PM, Staff 3 (LPN, Assistant DON) verified on [DATE] she allowed Resident 1 to leave AMA and did not call the guardian's emergency number to notify the guardian of the situation but instead left a voice message on her main number. Staff 3 stated at the time of the [DATE] elopement, she believed Resident 1's previous guardianship papers had expired.On [DATE] at 3:49 PM, Staff 28 (CNA) stated Resident 1 was not safe to be in the community by herself/himself.On [DATE] at 3:53 PM, Staff 29 (LPN Unit Manager) stated Resident 1 left AMA on [DATE] and [DATE] and allowing the resident to leave AMA was a misunderstanding.On [DATE] at 4:00 PM, Staff 7 (RN) stated when Resident 1 left AMA on [DATE], there was no stopping her/him. Staff 7 stated he attempted to notify the guardian's primary number and not the emergency number because he was unaware there were additional contact numbers to reach the guardian. Staff 7 stated he did not call the police as he felt the resident was alert and oriented and was not aware the resident was not allowed to leave the facility. On [DATE] at 5:05 PM, Staff 1 (Administrator), Staff 2 (DON), and Staff 4 (Regional RN) verified Resident 1 left the faciity on [DATE] and [DATE].

Based on interview and record review it was determined the facility failed to develop a comprehensive assessment for 1 of 3 residents (#31) reviewed for tube feeding. This placed residents at risk for unmet nutritional needs and weight loss. Resident 31 was admitted to the facility in 4/2025 with diagnoses including a feeding tube. The 5/3/25 Admission Nutritional Status CAA indicated Resident 31 had nutritional problems or potential problem related to acute kidney failure, UTI, diabetes, severe septic shock, high blood pressure and Enteral feeding. (tube feeding.) The Admission Nutritional CAA did not include Resident 31's eating pattern, communication problems, resident or family input, or care plan considerations. On 5/22/25 at 11:57 AM Staff 22 (MDS Coordinator) acknowledged the 5/22/25 Admission MDS Nutritional CAA did not include Resident 31's current eating pattern, communication problems, resident or family input, or care plan considerations. Staff 22 acknowledged the 5/22/25 Admission MDS Nutritional CAA needed more information and was not comprehensive. On 5/22/25 at 1:56 PM Staff 2 (DNS) acknowledged the 5/22/25 Admission MDS Nutritional CAA did not include Resident 31's current eating pattern, communication problems, resident or family input, or care plan considerations. Staff 2 acknowledged the 5/22/25 Admission MDS Nutritional CAA was not comprehensive and her expectation was for staff to make the CAA person centered for Resident 31.

Based on interview and record review, it was determined the facility failed to protect the resident's right to be free from abuse for 2 of 2 sampled residents (#s 32 & 208) reviewed for abuse. This placed residents at risk for mental anguish and abuse. Findings include: Review of the facility's 3/2025 Freedom from Abuse, Neglect and Exploitation Policy and Procedures revealed: Definition of willful: The individual must have acted deliberately (not an inadvertent or accidental action), not that the individual must have intended to inflict injury or harm. 1. Resident 32 admitted to the facility in 2022 with diagnoses including stroke affecting dominant side and mood disorder. Resident 32's 3/15/25 Quarterly MDS indicated the resident was severely cogitatively impaired. 2. Resident 208 readmitted to the facility in 3/2025 with diagnoses including dementia and agitation. Resident 208's 3/15/25 Admission MDS indicated the resident was cognitively intact. On 4/3/25 at 8:30 PM, an Alleged Abuse incident report completed by Staff 1 (Administrator) revealed Staff 11 (RN) reported Staff 12 (CNA) and Staff 18 (CNA) witnessed Resident 208 touching Resident 32's breast at approximately 5:45 PM, in the dining room. On 4/3/25 Staff 12's (CNA) witness statement indicated around dinnertime, she observed Resident 208 attempting to touch Resident 32's chest. Staff 12 reported the incident to Staff 16 (RN) and was instructed to move Resident 208 away from Resident 32. Staff 12 informed Resident 208 that she/he needed to sit in a different location at which point Resident 208 became angry and attempted to approach Resident 32 again. On 4/3/25 Staff 16's (RN) witness statement indicated he was notified by a CNA about difficulty keeping Resident 208 out of the dining room and away from Resident 32. Staff reported Resident 208 had been re-directed and removed from the area several times but continued to return. Staff 16 instructed the CNAs to keep Resident 208 away from Resident 32, to continue to monitor both residents, and to notify him if Resident 208 attempted to approach Resident 32 again. On 4/3/25 Staff 17's (CNA) witness statement indicated she was trying to help move Resident 208 away from Resident 32. Resident 208 was saying do you want some of this? while pointing downward and looking towards Resident 32. Staff 17 stated Resident 208 was resistive at first then stopped trying to approach Resident 32. On 4/3/25 Staff 18's (CNA) witness statement indicated he witnessed Resident 208 touching Resident 32's breast in the dining room and Staff 12 moved Resident 208 away from Resident 32. On 4/11/2025 at 12:55 PM, a social services note indicated staff were called to Resident 208's room in response to reports of unruly behavior and verbal threats directed toward staff and other residents. The facility contacted the local police department and emergency medical transport (EMT) to facilitate a psychiatric evaluation at an emergency department. During the EMT's attempt to transport the resident, Resident 208 reportedly stated, If I get you alone, I'll knock your fucking teeth out. The resident's family was notified of the incident and informed that, due to the nature of the behavior, Resident 208 would not be readmitted to the facility following the evaluation. On 4/11/2025 at 3:09 PM, a social services note documented that Resident 208 underwent a psychiatric evaluation and was subsequently returned to the facility. On 4/17/2025 at 4:59 PM, an alert note documented Resident 208 was verbally aggressive toward staff and another resident. While staff were assisting another resident in the hallway, Resident 208 reportedly stated an aggressive remark. The other resident turned around in response to the verbal outburst, at which point Resident 208 directed the comment, Fuck you big guy, what are you going to do about it? toward the resident. Staff intervened however, removal of Resident 208 from the area was challenging due to continued aggression. On 5/21/25 at 2:31 PM, Staff 18 (CNA) confirmed he witnessed Resident 208 touch Resident 32's breast in the dining room. Staff 18 separated both residents and asked Staff 12 to tell the charge nurse while he kept the residents apart. On 5/22/25 at 1:51 PM, Staff 12 (CNA) stated when she brought another resident into the dining room for dinner she saw Resident 208 touch Resident 32's breast. Staff 12 stated when she tried to separate Resident 208 she/he tried to follow Resident 32 and became verbally aggressive. On 5/22/25 at 8:45 PM, Staff 11 (RN) stated on 4/3/25 at approximately 8:15 PM, Staff 12 and Staff 18 reported earlier that day they both witnessed Resident 208 touch Resident 32's breast in the dining room during dinner time. Staff 11 stated immediate safety interventions were put into place, residents' family and appropriate staff were notified. On 5/23/25 at 11:48 AM, Staff 1 (Administrator) acknowledged the sexual contact between Resident 32 and Resident 208. Staff 1 stated neither resident had the mental capacity to consent. Staff 1 stated he did not believe the resident's actions were willful and did not believe the facility could have prevented the resident's behavior or rule out abuse or neglect. Staff 1 acknowledged the facility had an obligation to ensure residents were free from abuse.

Based on interview and record review it was determined the facility failed to ensure alleged violations involving sexual abuse were reported immediately, but no later than two hours after the allegation is made for 2 of 2 sampled residents (#s 32 and 208) reviewed for abuse. This placed residents at risk for abuse. Findings include: 1. Resident 32 admitted to the facility in 2022 with a diagnoses including stroke affecting dominant side and mood disorder. Resident 32's 3/15/15 Quarterly MDS indicated the resident was (severely cognitively impaired). 2. Resident 208 readmitted to the facility in 2025 with diagnoses including dementia and agitation. Resident 208's 3/15/25 Admission MDS indicated she/he was (cognitively intact). Review of the incident investigation dated 4/3/25 indicated at approximately 5:45 PM, Staff 12 (CNA) and Staff 13 (CNA) witnessed Resident 208 touch Resident 32's breast in the dining. At approximately 8:15 PM, Staff 12 and Staff 13 notified Staff 11 (RN). A FRI was received on 4/3/25 at 9:23 PM, the report indicated staff witnessed Resident 208 touched Resident 32's breast at 5:45 PM. On 5/22/25 at 8:45 PM, Staff 11 (RN) stated on 4/3/25 at approximately 8:15 PM, Staff 12 and Staff 13 reported at approximately 5:30 PM, they both witnessed Resident 208 touch Resident 32's breast in the dining. Staff 11 stated she notified Staff 1 (Administrator) but did not submit the FRI. On 5/23/25 at 11:48 AM, Staff 1 (Administrator) acknowledged the facility failed to report alleged allegations of sexual abuse timely to the State Agency.

Based on observation, interview, and record review, it was determined the facility failed to ensure dialysis (a procedure which removes waste products and excess fluid from the blood when the kidneys are no longer functioning properly) services were completed, including monitoring and communication with the dialysis provider for 1 of 1 sampled resident (#44) reviewed for dialysis. This placed residents at risk for delayed treatment and medical complications related to dialysis. Findings include: Resident 44 was admitted to the facility in 3/2025 with diagnoses including heart failure and end stage renal disease. The 3/11/25 Admission MDS indicated Resident 44 had a BIMS score of 12 (moderate cognitive impairment), received a therapeutic diet, and was at risk for fluid overload due to end stage renal disease. a. A 3/10/25 physician order indicated nursing staff were to complete the post-dialysis form after Resident 44 returned from dialysis. Staff were to ensure the resident returned with the Pre-Dialysis Assessment and Communication Form completed and follow up as indicated with dialysis if the form was not returned with the resident every Monday, Wednesday, and Friday. A 4/8/25 revised care plan revealed Resident 44 received dialysis on Mondays, Wednesdays, and Fridays. A review of the 5/2025 Pre/Post Dialysis Assessment forms revealed on 5/12/25, 5/14/25, and 5/21/25 dialysis forms were either incomplete or contained inaccurate weights for the day of dialysis. On 5/22/25 at 8:38 AM, Resident 44 stated she/he took forms with her/him to dialysis and dialysis was to FAX the information back to the facility. On 5/22/25 at 8:42 AM, Staff 10 (LPN) stated he worked both night and day shifts. Staff 10 indicated the night nurse was responsible to ensure the post-dialysis information was received from dialysis by FAX and the dialysis assessment form was completed. Staff 10 stated the expectation was to obtain accurate weights and vitals on the day of dialysis from facility staff for pre-dialysis data. On 5/22/25 at 9:38 AM, Staff 6 (Unit Manger) stated it was difficult to get the dialysis forms returned from dialysis. Staff 6 stated nursing staff was expected to follow up with dialysis in order to accurately assess and monitor Resident 44. Staff 6 stated correct data on Resident 44 was needed for all dialysis assessments and the expectation for dialysis care for Resident 44 was not met. On 5/23/25 at 1:07 PM, Staff 2 (DNS) stated she expected staff to contact dialysis if the dialysis information was not received. Staff 2 acknowledged timely and complete dialysis assessments for Resident 44 were necessary. b. The 2021 facility's Diet and Nutrition Care Manual indicated a Liberalized Renal Diet for dairy products may be limited if phosphorous (a mineral) was a concern. A 3/10/25 Diet Profile indicated Resident 44 was to receive a renal diet (foods lower in sodium, potassium, and phosphorus), large portions, and disliked meat and eggs. A 5/5/25 Nutrition Communication from dialysis indicated Resident 44's phosphorus levels were elevated and a high-protein, mostly vegan diet was recommended with a note which indicated Resident 44 will consume small amounts of cottage cheese. Recommendations included a double portion of protein to include tofu and beans due to the resident's hunger. An acknowledgement note handwritten by Staff 3 (Assistant Director of Nursing) on the Nutrition Communication form indicated Resident 44 already received large portions and extra protein. A 5/19/25 Nursing Progress Note indicated Resident 44 returned from dialysis with a note which indicated the resident had excessive weight gain; the dialysis center was unable to remove all fluid and requested Resident 44 be placed on a low sodium diet. On 5/21/25, an undated Sack Lunches for Renal Diets list was observed on the snack refrigerator door located near the the dining room. The posted list included a list of items not appropriate for renal diets. Cottage cheese (a food high in sodium and phosphorus) was not on the list. On 5/20/25 at 5:00 PM, Resident 44 stated staff, from the dialysis center, indicated her/his diet needed more protein. Resident 44 stated she/he received few protein options with her/his meals. Review of Resident 44's 5/20/25 breakfast meal ticket revealed no protein was provided. On 5/21/25 at 8:55 AM, Staff 5 (Dietary Manager) stated there was a notebook in the dining room which included a list of all resident diets with diet education. Staff 5 indicated the notebook was available for everyone, including nursing staff. On 5/21/25 at 1:20 PM and 1:24 PM, Staff 8 (CNA) and Staff 9 (CNA) stated Resident 44 was often hungry and cottage cheese was routinely provided to Resident 44 as a snack because she/he did not like meat or eggs. Staff 9 and Staff 8 were unaware to limit cottage cheese for Resident 44 and had no knowledge of the resident diet list or notebook. On 5/22/25 at 11:13 AM, Staff 3 stated weekly meetings occurred with Staff 7 (RD) and Resident 44's diet was not updated timely. Staff 3 stated a faster process was needed to ensure diets were updated. On 5/22/25 at 12:02 PM, Staff 5 stated the communication of diet orders for Resident 44 was confusing. Staff 5 acknowledged improved renal diet information and diet training for nursing staff was needed. On 5/22/25 at 12:30 PM, Staff 7 acknowledged she was aware of the 5/5/25 dietary communication related to Resident 44's dietary needs, which was not yet fully addressed. Staff 7 stated some cottage cheese for Resident 44 was acceptable and more direct communication between dialysis staff and Staff 7 was expected to timely address the nutritional needs of Resident 44. On 5/23/25 at 1:07 PM, Staff 2 (DNS) acknowledged improved dietary information, direction, and training were necessary related to Resident 44 and renal diets.

Based on interview and record review it was determined the facility failed to follow up on dental services for 1 of 1 sampled resident (#6) reviewed for dental services. This placed residents at risk for unmet dental health needs. Findings include: A 3/2023 facility Dental Service policy indicated the facility was to assist the resident in making dental appointments if necessary or requested. Resident 6 was admitted to the facility in 5/2021 with diagnoses including bipolar disorder (mental health condition characterized by extreme moods) and chronic pain. A 12/5/24 IDT (Interdisciplinary Team) Care plan Conference/Welcome Meeting Form indicated Resident 6 requested follow-up appointments for dental work that began during the prior months. A 3/4/25 Quarterly MDS indicated Resident 6 had a BIMS score of 14 (cognitively intact) and had obvious or probably cavities or broken teeth. A 3/11/25 IDT Care Plan Conference/Welcome Meeting Form indicated Resident 6 required dental services, including routine cleaning. A 3/13/25 revised care plan indicated Resident 6 required one staff to set up or assist with oral care. On 5/19/25 at 1:54 PM, Resident 6 stated she/he requested dental work because of five areas in her/his mouth that needed attention. Resident 6 reported she/he continued to request assistance with dental appointments during care conferences, but no appointments occurred. On 5/20/25 at 4:17 PM, Staff 20 (CNA) stated Resident 6 had no dental pain. Staff 20 stated Resident 6 often remained in bed, the resident was able to perform her/his own dental care, and declined offers to set up her/his tooth brush and toothpaste when tired. On 5/21/25 at 10:51 AM, Staff 4 (Social Service Director) recalled Resident 6's requests for dental services during the 12/2025 and 3/2025 care conferences. Staff 4 stated Staff 14 (Receptionist) was responsible to schedule dental appointments for residents and was expected to update Staff 4 regarding Resident 6's dental appointment needs. Staff 4 stated she expected updates within two weeks of Resident 6's dental appointments and acknowledged the follow up was missed. On 5/21/25 at 12:02 PM, Staff 14 stated she was aware Resident 6 had a dental appointment on 1/22/25 and was to receive provider notes upon Resident 6's return. Staff 14 stated she did not contact the provider for notes when Resident 6 returned without documentation. On 5/23/25 at 1:00 PM, Staff 2 (DNS) stated the transportation company that transported Resident 6 to the 1/22/25 dental appointment reported Resident 6 had a fractured tooth. Staff 2 expected staff to follow-up on all resident appointments.

Based on observation and interview it was determined the facility failed to properly dispose of expired medications for 1 of 1 medical storage room, 2 of 3 medication carts, and 2 of 3 resident medication storage refrigerators reviewed for medication storage. This placed residents at risk for lack of medication efficacy and adverse reactions from expired medications. Findings include: During a review of the medication storage room on 12/2/24 at 12:34 PM Staff 4 (RN) verified the following were found: - 11 bottles of alpha lipoic acid (a supplement) with an expiration date of 11/2024 - two bottles of naproxen 220 mg (a pain reliever) with an expiration date of 11/2024 - one bottle of Prosource No Carb (a supplement) with an expiration date of 12/1/24 - two bottles of Osmolyte 1.5 (a supplement) with an expiration date of 8/2024 - six bottles of Robitussin (a cough suppressant) with an expiration date of 11/2024 During a review of the 300-hall resident medication storage refrigerator on 12/2/24 at 12:58 PM Staff 5 (LPN) verified the following were found: - three bags of IV Vancomycin 900 mg (an antibiotic medication administered directly into the vein through a flexible tubing) were ordered for a resident who discharged on [DATE] with a use by date of 10/24/24 During a review of the 100-hall resident medication storage refrigerator on 12/2/24 at 1:25 PM Staff 6 (LPN/Unit Manager) verified the following was found: - a carton of moderately thickened water (water with an added thickening agent) with a best by date of 10/14/24 During a review of the 300-hall medication cart on 12/2/24 at 2:53 PM Staff 5 (LPN) verified the following were found: - two bottles of Robitussin with an expiration date of 11/2024 - one bottle of naproxen 220 mg with an expiration date of 11/2024 - one bottle of Fem Flora Probiotic (a supplement) with an expiration date of 4/2024 - one bottle of Active Liquid Protein (a supplement) opened 5/2024 with no expiration date - one bottle of nitroglycerin (a chest pain reliever) with an expiration date of 1/2022 During a review of the 100-hall medication cart on 12/2/24 at 5:04 PM Staff 7 (CMA) verified the following were found: - one bottle of Vitamin D 25 mcg (a supplement) with an expiration date of 11/2024 - one bottle of naproxen 220 mg with an expiration date of 11/2024 - one bottle of Robitussin with an expiration date of 11/2024 During an interview on 12/2/24 at 5:34 PM Staff 9 (Vice President of Clinical Services) stated the expectation was for all expired medications to be removed from medication storage areas and medication carts.

Based on interview and record review it was determined the facility failed to update a resident's POLST (physician orders for life sustaining treatment; end of life choices) for 1 of 4 sampled residents (#36) reviewed for ADLs. This placed residents at risk for end-of-life choices not being honored. Findings include: Resident 36 admitted to the facility in 2/2024 with a diagnosis of a brain injury. A POLST dated 2/5/24 indicated Resident 36 was to be resuscitated if her/his heart and breathing stopped. A 3/1/24 admission MDS and 6/1/24 quarterly MDS revealed Resident 36 had moderate cognitive impairment, but was able to make her/his needs known. An 8/26/24 Interdisciplinary Care Conference Form revealed Resident 36 notified staff she/he wanted to change her/his code status (POLST) to a DNR (do not resuscitate) status. At this time of the survey Resident 36's record did not include an updated POLST. On 12/4/24 at 10:59 AM Staff 37 (Social Services) acknowledged during the 8/2024 care conference Resident 36 voiced her/his desire to change her/his POLST from full resuscitation to no resuscitation and it was not updated.

Based on interview and record review it was determined the facility failed to ensure transfer notices with appeal rights were provided in writing to residents and their representatives, and to ensure the Office of the State Long-Term Care Ombudsman was notified of resident hospitalization s for 2 of 2 sampled resident (#s 4 and 36) reviewed for hospitalization s. This placed residents at risk of lack of access to an advocate to inform them of their options and rights, and a decreased quality of life. Findings include: Resident 4 admitted to the facility in 3/2021 with diagnoses including epilepsy. A review of Resident 4's nursing progress notes revealed she/he was discharged to the hospital on 10/30/24 due a seizure, and was readmitted to the facility on [DATE]. No evidence was found in Resident 4's clinical record to indicate a transfer notice with appeal rights was provided in writing to her/his representative or the Office of the State Long-Term Care Ombudsman was notified of the resident's transfer to the hospital. On 12/4/24 at 1:53 PM Staff 2 (DNS) stated the facility did not have a system in place to ensure representatives and the ombudsman were notified when a resident discharged from the facility as required. 26991 2. Resident 36 admitted to the facility in 2/2024 with a diagnosis of a brain injury. A Progress Note dated 8/21/24 revealed Resident 36 was admitted to the hospital on 8/21/24. Resident 36's record did not include documentation to indicate the ombudsman was notified of the transfer to the hospital. On 12/4/24 at 12:08 PM Staff 37 (Social Services) stated she was not aware who was responsible to notify the the ombudsman of resident transfers to the hospital. On 12/4/24 at 12:14 PM a request was made to Staff 2 (DNS) to provide documentation the ombudsman was notified of Resident 36's transfer to the hospital. No additional information was provided.

Based on observation, interview, and record review it was determined the facility failed to assist residents with hygiene for 2 of 4 sampled residents (#s 8 and 36) reviewed for ADLs. This placed residents at risk for lack of dignity. Findings include: 1. Resident 8 admitted to the facility in 5/2021 with a diagnosis of Parkinson's disease. A 9/10/24 annual MDS revealed Resident 8 was cognitively intact, weak, and had an ADL impairment which required staff to assist with personal hygiene. A Shower form dated from 11/6/24 through 12/6/24 revealed Resident 8 had a shower or bed bath on multiple dates including 11/30/24 and 12/4/24. On 12/2/24 at 1:23 PM, 12/4/24 at 3:37 PM, and 12/5/24 at 11:15 AM Resident 8 was observed to have a mustache and a beard which was starting to grow in. Resident 8 stated she/he preferred to keep a mustache but otherwise liked to be clean shaved. Resident 8 also stated staff needed to help her/him and they usually helped about every two months. On 12/4/24 at 9:28 AM Staff 33 (CNA) stated it did not look like Resident 8 was shaved for awhile. On 12/5/24 at 12:52 PM Staff 6 (LPN Unit Manager) was notified Resident 8 was not shaved when provided bathing on 12/5/24 and Staff 6 indicated she would address Resident 8's shaving preference. 2. Resident 36 admitted to the facility in 2/2024 with a diagnosis of a brain injury. A 3/1/24 admission MDS and 12/2/24 quarterly MDS revealed Resident 36 had moderate cognitive impairment, was able to make needs known, and was dependent for ADL care including personal hygiene. A 11/5/24 through 12/5/24 Shower form revealed Resident 36 received bathing on Tuesday and Friday including 11/29/24 and 12/3/24. On 12/3/24 at 8:28 AM Resident 36 stated she/he liked having a mustache but preferred to not have a beard. Resident 36 stated staff had to help her/him shave. On 12/4/24 at 9:28 AM Staff 34 (Agency RN) stated Resident 36 received a bed bath on 12/3/24 and verified she/he was not shaved. On 12/5/24 at 12:52 PM Staff 6 (LPN Unit Manager) was notified Resident 36 was not shaved when provided bathing on 12/3/24 and Staff 6 indicated she would address Resident 36's shaving preference.

Based on interview and record review it was determined the facility failed to follow physician's orders and provide care and services to maintain the highest practicable level of well-being for 1 of 7 sampled residents (# 36) reviewed for hospitalization . Findings include: 1. Resident 36 admitted to the facility in 2/2024 with a diagnosis of brain injury. An 8/9/24 Encounter note by Staff 36 (Physician) revealed Resident 36 was referred to GI (gastrointestinal; specialty in digestive system issues) and the Referral is in place to GI for liver disease. An 8/16/24 Encounter note by Staff 36 revealed Resident 36 was assessed for a change in condition. At the time of the assessment Resident 36 was observed to be at her/his baseline. The encounter notes included Resident 36 had liver disease and new orders were provided which included a note Is there GI follow up please .? Resident 36's clinical record revealed no GI consult report. On 12/4/24 at 8:50 AM Staff 22 (LPN) stated if a physician note indicated a referral was to be made, Staff 35 (Reception) was notified, and she made the referrals. On 12/4/24 at 8:55 AM Staff 35 stated she made appointments and set up rides for residents. Staff 35 was asked if a GI appointment was made for Resident 36. No additional information was provided. On 12/4/24 at 11:24 AM Staff 30 (LPN Unit Manager) stated Staff 36 treated Resident 36's liver condition and the resident did not need to go to a GI specialist. Staff 30 acknowledged Staff 36 wrote the note for a GI consult. Staff 30 was asked to documentation indicating a GI consult was not required. No additional information was provided. 35855

Based on interview and record review it was determined the facility failed to ensure falls were evaluated timely and care plan interventions were updated, appropriate and followed for 2 of 2 sampled resident (#s 12 and 32) reviewed for accidents. This placed residents at risk for accidents. Findings include: 1. Resident 12 admitted to the facility in 10/2024 with diagnoses including stroke and low blood pressure. An 10/9/24 Un-witnessed Fall investigation revealed Resident 12 crawled in her/his room to the doorway and slid herself/himself out of her/his chair. Resident 12 was reminded to use her/his call light and Zoloft (antidepressant medication) was added on 10/10/24 to assist with her/his impulsive behaviors. Investigation notes indicated the investigation was dated 10/30/24 (21 days after the incident) and the care plan was followed. An 10/11/24 at 7:30 AM Un-witnessed Fall investigation had no description of Resident 12's fall and the investigation notes were dated 10/30/24 (19 days after the incident). An 10/11/24 at 7:15 PM Un-witnessed Fall investigation revealed Resident 12 was found on the floor on her/his knees, bilateral fall mats were placed and the investigation notes were dated 10/30/24. The 10/2025 TAR indicated from 10/11/24 through 11/4/24 nurses were to ensure Resident 12 was not left unattended in her/his room with frequent safety checks. An 10/12/24 Admission MDS revealed Resident 12 was moderately cognitively impaired, was frequently incontinent of bowel and bladder, and had two or more falls in the facility since admission. An 10/12/24 Nursing Note indicated a late entry for alert charting for Resident 12's falls and antidepressant medication. An 10/13/24 Un-witnessed Fall investigation revealed Resident 12 had a bad dream and was assisted back to bed with continued observation through the resident's open door. Resident 12's Zoloft was scheduled to increase on 10/15/24 to her/his previous home dose. No additional care plan interventions were found. The investigation notes were dated 10/30/24 (17 days after the incident). An 10/14/24 Un-witnessed Fall investigation revealed Resident 12 was found on the floor behind a chair in her/his room with one non-slip sock on, was incontinent of urine and the addition of a sleep aid was planned for the next provider visit on 10/17/24. No additional care plan interventions were found. The investigation notes were dated 10/30/24 (16 days after the incident). An 10/20/24 Un-witnessed Fall investigation revealed Resident 12 was found at her/his bedside and rolled out of bed when she/he tried to get something. Resident 12 was evaluated by the interdisciplinary team and it was decided to add a bolster mattress as fall prevention care. The investigation notes were dated 10/30/24 (10 days after the incident). A 11/13/24 revised care plan indicated on 10/11/24 bilateral fall mats were in place, on 10/20/24 the use of her/his low bed was documented and on 10/23/24 a bolster mattress and long handled reacher were implemented. On 12/6/24 at 12:49 PM Staff 6 (LPN-Unit Manager) stated she was unaware the nursing intervention to check and not leave Resident 12 unattended stopped on 11/4/24. Staff 6 acknowledged Resident 12's fall investigations were not thorough and completed timely which would ensure fall interventions were evaluated, in place and the care plan updated. 2. Resident 32 admitted to the facility in 10/2024 with diagnoses including dementia and pain in the right hip. The 10/20/24 Admission MDS indicated Resident 32 was severely cognitively impaired and had falls prior to admission. The 10/23/24 Un-witnessed Fall investigation revealed Resident 32 was observed to walk behind her/his wheelchair without assistance and was observed with a hematoma (a collection of blood that pools in the tissue after an injury) to the left side of her/his forehead, which was consistent with the handle bars of her/his wheelchair. The investigation was completed on 11/21/24 (28 days after the incident) and indicated the incident was unavoidable due to Resident 32's lack of safety awareness. The investigation indicated staff performed hourly safety checks, monitored the resident for three hours, and kept Resident 32 visible when she/he was in her wheelchair to prevent further falls. The 10/28/24 Un-witnessed Fall investigation revealed Resident 32 was found on the floor after a fall, and indicated the resident attempted to walk to the bathroom and hit her/his head. The investigation was completed on 11/25/24 (28 days after the incident) and indicated to offer toileting to Resident 32 upon rising, after meals and before bed to prevent further falls. The 11/11/24 Un-witnessed Fall investigation revealed Resident 32 was found on her/his back in front of the bathroom, the resident was monitored, and the care plan was in process. A 11/25/24 (14 days after the incident) note indicated, due to the resident's cognition, Resident 32 did not understand how to use her/his call light and an easier to operate call light was put into place. A 11/11/24 revised care plan indicated Resident 32 relied on one staff to assist with toileting and was at risk for falls with interventions which included: to use push palm call light for the resident, ensure her/his call light was within reach, toilet the resident upon rising, after meals and before bed, provide reminders, reorientation and cueing as needed, and Resident 32 needed activities to provide distractions that minimized falls. The care plan did not indicated the use of bilateral fall mats next to her/his bed or to have her/his bed in the lowest position. On 12/2/24 at 11:57 AM Resident 32 was observed in her/his bed resting with bilateral fall mats and her/his bed in the lowest position. On 12/3/24 at 8:33 AM Staff 39 (Regional Director of Clinical) was unable to provided documentation Resident 32 was assessed for the use of her/his push palm call light. On 12/4/24 at 11:30 AM Staff 21 (CNA) stated there were fall interventions on Resident 32's care plan which were not applicable to the resident. Staff 21 stated Resident 32 used briefs and was unable to be toileted or use her/his push palm call light because of her/his cognition. On 12/4/24 at 12:20 PM Staff 32 (CNA) stated the utilization of falls mats and her/his bed in the lowest position were not in Resident 32's care plan, but were used as interventions by staff to prevent her/his falls. On 12/4/24 at 3:58 PM Staff 30 (LPN-Unit Manager) stated fall mats for Resident 32 should not be used since the mats were a trip hazard for the resident and the care plan should be updated to have her/his bed in the lowest position. Staff 30 stated toileting for Resident 32 was appropriate and the care plan should be followed. Staff 30 acknowledged the resident's fall investigations were not completed timely and resulted in attempts to reduce falls that were not applicable for Resident 32.

Based on interview and record review it was determined the facility failed to ensure residents received accurate provision of prescribed medications for 3 of 6 sampled residents (#s 2, 4 and 13) reviewed for medications and hospitalization s. This placed residents at risk for not receiving medications as prescribed. Findings include: 1. Resident 2 was admitted to the facility in 12/2020 with diagnoses including heart failure. Review of the revised care plan dated 3/15/23 revealed Resident 2 had altered cardiovascular status due to hypotension with interventions which included to administer medications as ordered and monitor vital signs. Physician orders signed 11/17/24 instructed staff to administer metoprolol succinate (to treat chest pain, heart failure and high blood pressure) one time a day for hypertension, and to hold the medication if the resident's SPB (systolic blood pressure; the measure of force of blood against the artery walls while the heart beats) measured less than 100, or her/his DPB (diastolic blood pressure; the force of blood against the artery walls when the heart is relaxed and refilling with blood) measured less than 50, or her/his heart rate was less than 45 beats per minute. A review of the 11/2024 and 12/2024 MARs revealed staff were to administer metoprolol succinate one time a day for hypertension and to hold for SPB less than 100, DPB less than 50, or heart rate less than 45. A review of Resident 2's health record revealed on 12/2/24 at 7:17 AM Resident 2 was given metoprolol succinate when her/his blood pressure was documented as 96/57. A review of Resident 2's health record revealed on 12/2/24 at 4:00PM, Resident 13's blood pressure was documented as 174/70 and metoprolol succinate was administered. An interview on 12/7/24 at 9:31 AM with Staff 1 (Administrator) Staff 3 (Assistant Administrator), Staff 2 (DNS), Staff 9 (Vice President of Clinical), and Staff 31 (Senior Clinical Reimbursement), Staff 31 stated they expected the physician order to be followed. Resident 4 was admitted to the facility in 3/2021 with epilepsy. The 9/30/24 MDS indicated Resident 4 was rarely or never understood and was severely cognitively impaired. The 10/2024 MAR instructed staff to administer 25 milliliters lacosamide (an antiepileptic medication for seizures) two times a day for epilepsy with a start date of 1/22/24. The 10/26/24 8:00 AM and 8:00 PM MAR entries referred the reader to administration notes. Administration Notes revealed the following: -10/26/24 at 10:14 AM pharmacy was contacted, the order was refaxed, and the facility was waiting to receive the medication. -10/26/24 at 9:38 PM on order. A Nursing Note revealed the provider was notified on 10/28/24 that Resident 4 did not receive her/his lacosamide on 10/26/24. On 12/3/24 at 10:41 AM Staff 2 (DNS) and Staff 9 (Vice President) stated they expected staff to fax orders to the pharmacy the day the prescription was received. On 12/3/24 at 11:06 AM Witness 1 (Pharmacist) stated the physician would place an order to complete labs to check blood levels of the medication for a resident on lacosamide and the checks usually occurred during a change of dose. 3. Resident 13 admitted to the facility in 12/2021 with diagnoses including orthostatic hypotension (condition where blood pressure drops quickly when standing up after sitting or lying down). A review of the 12/2024 MAR revealed staff were to administer midodrine (to treat low blood pressure) three times a day for hypotension while awake, and to hold the medication if the resident's SPB (systolic blood pressure; the measure of force of blood against the artery walls while the heart beats) measured greater than 140. On 12/2/24 for the 4:00 PM Resident 13's blood pressure was 174/70 and the MAR revealed metoprolol succinate was administered. Physician orders signed 12/3/24 with a review period from 11/3/24 through 12/3/24 instructed staff to administer midodrine three times a day for hypotension with a start date of 6/24/24. In an interview on 12/7/24 at 9:33 AM with Staff 1 (Administrator), Staff 3 (Assistant Administrator), Staff 2 (DNS), Staff 9 (Vice President of Clinical), and Staff 31 (Senior Clinical Reimbursement), Staff 31 stated she expected the physician order to be followed.

Based on interview and record review it was determined the facility failed to address pharmacy recommendations for 1 of 5 sampled residents (#13) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include: It was determined this citation met the criteria for Past Noncompliance based on the following: On 11/26/24 the Past Noncompliance was corrected when the facility completed an initial audit on 11/22/24 and identified the facility failed to ensure pharmacy recommendations were not addressed. The Plan of Correction included: -Completion of an audit to ensure provider followed up was completed and documented in the resident chart. -Nurse Managers were educated by the [NAME] President of Clinical regarding requirements related to pharmacy consultant recommendations. The DNS was educated on a pharmacy recommendations tracking system and would start the tracking system relative to the 11/2024 pharmacist recommendations to ensure timely follow-up. -Audits would be completed monthly for three months to ensure pharmacy recommendations were addressed and completed appropriately. Findings would be reviewed and reported to the QAPI Committee monthly for three months and ongoing as needed to ensure compliance was sustained. Resident 13 admitted to the facility in 12/2021 with diagnoses including orthostatic hypotension (condition where blood pressure drops quickly when standing up after sitting or lying down). A review of the 9/30/24 and 10/31/24 Recommendation Summary for Medical Director and DON reports revealed Resident 13 was scheduled to receive midodrine (to treat low blood pressure) at 8:00 AM, 12:00 PM and 8:00 PM, and the manufacture recommended to administer within four hours of lying down to sleep due to increased risk of supine hypertension (high blood pressure while lying down) as well as to assist with symptoms of hypotension during waking hours. A recommendation was made was to adjust administration times to four hours prior to Resident 13 lying down for bed, at 8:00 AM, 12:00 PM and 4:00 PM. An 10/2024 MAR instructed staff to administer midodrine three times a day for hypotension. The MAR indicated Resident 13 received midodrine at 8:00 AM, 12:00 PM and 8:00 PM through the month of 10/2024. A 11/2024 MAR instructed staff to administer midodrine three times a day for hypotension. The MAR indicated Resident 13 received midodrine from 11/1/24 through 11/14/24 at 8:00 AM, 12:00 PM and 8:00 PM. The pharmacy recommendation for administrations at 8:00 AM, 12:00 PM and 4:00 PM was not implemented until 11/15/24. An interview on 12/7/24 at 9:33 AM with Staff 1 (Administrator) Staff 3 (Assistant Administrator), Staff 2 (DNS), Staff 9 (Vice President of Clinical), and Staff 31 (Senior Clinical Reimbursement) revealed the facility identified the above concern and the facility did not always receive pharmacist reports.

Based on interview and record review it was determined the facility failed to provide information regarding the facility's bed hold policy for 2 of 2 sampled residents (#s 4 and 36) reviewed for hospitalization . This placed residents at risk for lack of knowledge regarding the right to return to the same bed within the facility. Findings include: Resident 4 admitted to the facility in 3/2021 with diagnoses including epilepsy. A review of Resident 4's nursing progress notes revealed she/he was discharged to the hospital on 10/30/24 due a seizure and was readmitted to the facility on [DATE]. No documentation was found in Resident 4's clinical record the facility's bed hold policy was reviewed with the resident or the resident's representative upon discharge to the hospital. On 12/4/24 at 1:53 PM Staff 2 (DNS) stated the facility did not have a system in place to ensure residents and representative were notified of the bed hold policy when discharged from the facility. 26991 2. Resident 36 admitted to the facility in 2/2024 with a diagnosis of a stroke. Progress Notes dated 8/21/24 revealed Resident 36 was discharged to the hospital on 8/21/24. Resident 36's record did not include documentation to indicate Resident 36 or her/his representative were provided with a copy of the facility's bed hold policy. On 12/4/24 at 12:08 PM Staff 37 (Social Services) stated upon admission residents were provided the bed hold policy. Staff 37 stated she was not sure who provided one prior to hospitalization . On 12/4/24 at 12:11 PM Staff 34 (Agency RN) stated the nurse on duty provided the bed hold policy to the resident at the time of discharge to the hospital. If the policy was provided staff documented it in the resident's progress notes. On 12/4/24 at 12:14 PM a request was made to Staff 2 (DNS) to provide documentation Resident 36 or her/his representative were provided copy of the facility's bed hold policy on 8/21/24. No additional information was provided.

Based on interview and record review it was determined the facility failed to ensure residents were free from sexual abuse for 2 of 5 sampled residents (#s 15 and 16) reviewed for abuse. This failure, determined to be an immediate jeopardy situation, placed residents at risk for sexual abuse when staff witnessed repeated intimate nonconsensual sexual activity without completing assessments to determine ability to consent and without putting appropriate interventions in place. Findings include: The facility's 3/2023 facility Freedom from Abuse, Neglect and Exploitation policy indicated the following: - The facility will provide a safe resident environment and protect residents from abuse . this includes freedom from . sexual or physical abuse. - Sexual abuse is defined as non-consensual sexual contact of any type with a resident. - When abuse has been identified the facility is to take appropriate steps . to protect residents from additional abuse immediately which includes steps to prevent further potential abuse. - Report allegation to appropriate authorities within required timeframe's and conduct a thorough investigation. - Sexual abuse is indicated as non-consensual sexual contact of any type with a resident who appears to want the contact to occur but lacks the cognitive ability to consent. - Investigations of an allegation of sexual abuse will start with a determination of whether the sexual activity was consensual or not, taking into consideration the cognitive ability of the resident to consent. - Resident without cognitively ability to consent will not engage in sexual activity. - If a resident has a legal representative, the facility will ascertain which decisions the representative has the right to make, including consent for sexual activity. Resident 15 admitted to the facility in 2019, with diagnoses including cognitive communication deficit, vascular dementia and a stroke. Resident 15's 2/16/24 Quarterly MDS indicated severe cognitive impairment. Resident 15's clinical record indicated she/he was her/his own responsible party and Witness 2 (family friend) as the resident's responsible party and POA (Power of Attorney) of financial. Resident 16 admitted to the facility in 2022, with diagnoses including a stroke. Resident 16's 9/16/22 Admission MDS indicated severe cognitive impairment. Resident 16's clinical record indicated she/he was her/his own responsible party and Witness 1 (family member) as first emergency contact. A review of Resident 15 and Resident 16's Progress Notes from 5/19/24 through 5/21/24 revealed the following: - 5/19/24 Staff 6 (PT) found Resident 15 in the common area touching Resident 16 inappropriately. Staff 6 reported the details to Staff 7 (RN). Both residents were separated. Using Google translate, Resident 16 was asked if she/he allowed Resident 15 to touch her/him and indicated, yes. Nursing staff contacted both the unit manager and administrator. The note further indicated the encounter was investigated by management and the interaction was consensual. - On 5/20/24 at 11:19 AM, Staff 7 found Resident 15 and Resident 16 in the dining room touching each other. Both residents were educated they could not do it there as it was a public place. The note indicated the administrator was aware. - On 5/20/24 at 5:50 PM, Staff 8 (LPN) witnessed Resident 15 and Resident 16 in the front lobby. Both residents had their hands under clothing and touching groin and chest areas, kissing. Both residents were separated. Resident 15 was asked about the touching and the resident was unable to recall and had no memory of the incident. The administrator was contacted. Staff 8 noted neither [resident] can consent, and it was not the first time the behavior was witnessed. - On 5/20/24 at 7:44 PM, Staff 8 indicated he spoke with Staff 1 (Administrator) and Staff 1 stated he investigated, and ruled out abuse. Staff 8 indicated Staff 1 asked him if it was reported to the State. Staff 8 contacted Witness 3 (Resident 15's family) and informed him the administrator investigated the 2 previous incidents and ruled out abuse, per [Staff 1's] request. - On 5/21/24 at 9:54 AM and 9:58 AM, Staff 15 (Social Services) spoke with Resident 15 and Resident 16 about the interactions. Resident 15 stated interaction was consensual. Resident 16 was asked via Google translate and she/he stated the touching was, ok. - On 5/21/24 at 4:49 PM, the physician was notified and after further review the touching was consensual. Resident 15's Care Plan updated 5/21/24 indicated the resident engaged in intimate behaviors with another resident. Interventions included to encourage the resident to refrain from intimate expressions in public areas and guide the resident and her/his partner to a private room when intimate activity was desired. Resident 16's Care Plan updated 5/21/24 indicated the resident had a history of flirtatious behavior toward men. Interventions included to encourage the resident to refrain from intimate expressions in public areas and guide the resident and her/his partner to a private room when intimate activity was desired. A review of Resident 15 and Resident 16's clinical record from 5/19/24 through 5/21/24 revealed the following: - A 5/21/24 cognitive evaluation for Resident 15 indicated moderate cognitive impairment. - No updated cognitive evaluation was completed for Resident 16. - Resident 15 and Resident 16's physician was not contacted until 5/21/24 and only indicated the one incident on 5/19/24 was reported. - Care Plan revisions did not reflect both residents' cognitive impairment and the ability to consent to sexual intimacy. - No monitoring was in place to protect the residents' from further incidents. - Resident 15's responsible party (Witness 2) was not notified of the incidents. - Resident 16's family (Witness 1) was not contacted until 5/21/24. - There was no investigation conducted related to the three incidents on 5/19/24 and 5/20/24. - No facility sexual consent assessment was found for Resident 15 and Resident 16. - The State Survey Agency was not contacted until 5/21/24 at 3:42 PM, which only indicated the one incident on 5/19/24. Interviews conducted with Resident 15, Resident 16 and Witnesses indicated the following: - On 5/22/24 at 1:23 PM Resident 15 stated she/he did not believe she/he was in a relationship with another resident. Resident 15 stated she/he did not go around kissing anybody, and was not aware of touching or being intimate with another resident. Resident 15 stated it would not be ok with her/him if she/he was kissing another resident even if she/he liked another resident. - On 5/22/24 at 2:12 PM Resident 16 was interviewed with the assistance of Witness 1 providing translation. Resident 16 stated she/he had a boyfriend and she/he touched and kissed her/him. Resident 16 was unable to state the other resident's name and laughed and giggled throughout the interview. - On 5/22/24 at 12:41 PM and 2:32 PM Witness 1 (Resident 16's family member) stated the facility contacted her on 5/21/24. Witness 1 stated she was told Resident 16 engaged in inappropriate behavior in the hallway with another resident. Witness 1 stated the facility used Goggle translate to communicate to Resident 16 and stated Google translate did not always translate correctly. Witness 1 stated ever since Resident 16 had a stroke, the resident's family made the decisions about her/his care. Witness 1 stated Resident 16 was not her/himself and was not able to state what she/he wanted and had difficultly communicating. Witness 1 stated Resident 16 was not capable of making decisions related to sexual intimate behaviors and it was common sense (resident was cognitively impaired). Witness 1 stated Resident 16 may have said, yes at the moment and laugh but was not able make any real decisions. Witness 1 stated she was shocked, and it was not culturally appropriate for Resident 16 to engage in intimate behaviors in public. Witness 1 stated the facility did not ask the family if they agreed with Resident 16 engaging in the intimate behaviors with another resident. Witness 1 stated the resident's family did not give permission for Resident 16 to engage in intimate behaviors. - On 5/22/24 at 12:21 PM, Witness 3 (Resident 15's family member) stated the facility contacted him for the first time on 5/21/24 regarding the identified incidents. Witness 3 stated he was informed the intimate acts with Resident 15 occurred a few times, and was taken aback. Witness 3 stated Resident 15's conduct was out of character and was not aware the incidents took place in public areas. Witness 3 stated the facility informed him the incidents were consensual and he was very surprised. Witness 3 stated he agreed it was appropriate to keep both residents separated. Witness 3 further stated Witness 2 should have been contacted as well as she was Resident 15's POA and responsible party. - On 5/22/24 at 3:13 PM, Witness 2 (Responsible party) stated she was the responsible party for Resident 15. Witness 2 stated Witness 3 was also involved with Resident 15's care. Witness 2 stated she was not aware nor contacted about any of the identified incidents between Resident 15 and Resident 16 and expected the facility to contact her about the incidents. Witness 2 stated she was surprised and could not imagine Resident 15 engaging in intimate acts. Witness 2 stated she did not believe Resident 15 was cognitively able to consent as Resident 15 had multiple strokes and seizures. Witness 2 stated due to Resident 15's cognitive impairments, she/he was extremely suggestible to others influences. Witness 2 stated Resident 15 was unable to make her/her own decisions and her/his, logic went away a long time ago. Witness 2 further stated the intimate acts Resident 15 engaged in was out of character and she did not approve of the behaviors. Interviews conducted with facility Staff revealed the following: - On 5/21/24 at 12:40 PM, Staff 12 (CMA) stated she was aware of Resident 15 and Resident 16 being found together two to three times. Staff 12 stated she believed Resident 15 was not cognitively able to consent and was not sure about Resident 16 due language barrier. - On 5/21/24 at 1:14 PM, Staff 14 (CNA) stated she regularly cared for Resident 15. Staff 14 stated Resident 15 was confused and Resident 16 seemed with it. Staff 14 stated she did not witness any of the incidents but was aware they were found together a few times. - On 5/21/22 at 1:46 PM, Staff 5 (LPN) stated on 5/19/24 a sexual incident between Resident 15 and Resident 16 was observed by Staff 6 (PT) and was reported to her. Staff 5 stated two more incidents between Resident 15 and Resident 16 occurred on the morning and evening of 5/21/24. Staff 5 stated Staff 8 (LPN) called Resident 15's family and was told by Staff 1 (Administrator) to not report the incident to the State. Staff 5 stated she was not aware of either resident's family being contacted prior to the third incident. Staff 5 stated Resident 15 was alert and oriented to self only and Resident 16 was difficult to assess due to being non-English speaking. Staff 5 stated on 5/20/24 Staff 1 told staff to not worry about keeping the residents separate and the behavior was ok. - On 5/21/24 at 3:47 PM, Staff 8 stated on the evening of 5/21/24 he was heading inside the facility and was able to see through the front window. Staff 8 stated he saw Resident 15 had her/hands under Resident 16's shirt and Resident 15 had her/his hand down Resident 16's pants, the residents were kissing. Staff 8 stated he asked staff what was going on and was told Staff 1 said it was ok for the behavior to occur. Staff 8 stated he spoke with Resident 15 about 10 minutes later after the incident and Resident 15 was unable to recall what happened. Staff 8 stated he believed it was best to keep the residents separated. Staff 8 stated he looked in the progress notes and read the same type of incident had occurred twice before. Staff 8 stated he contacted both Staff 1 and the unit manager. Staff 8 stated Staff 1 asked if he had reported the observed incident to the State. Staff 8 stated he told Staff 1 it was his responsibility to notify the State. Staff 8 stated he believed Resident 15 was not cognitively able to consent to sexual behaviors as the resident was not able to recall the incident that had just occurred. Staff 8 stated he was unsure if Resident 16 was able to consent due to the language barrier. Staff 8 stated he contact Resident 15's family and was told by Staff 1 to inform the family two investigations had been completed and no abuse was determined. Staff 8 stated he was not asked to write a statement regarding the incident he observed. - On 5/22/24 at 11:32 AM and 5/23/24 at 9:47 AM, Staff 7 (RN) stated on 5/19/24 she was informed by Staff 6 of a sexual incident between Resident 15 and Resident 16. Staff 7 stated on the morning of 5/21/24 she observed Resident 15 and Resident 16 in the dining room caressing each other. Staff 7 stated Resident 16 moved away once she called out the resident's name. Staff 7 stated she removed Resident 16 from the dining room. Staff 7 stated she was told by Staff 1 to direct the residents to a private area when the residents were observed engaging in intimate behaviors in public. Staff 7 stated Resident 16 was aware but confused about what she/he was doing. Staff 7 stated she was not sure if Resident 15 was able to consent. Staff 7 stated Resident 16's family made health-related decisions for her/him. Staff 7 stated she was not aware if the residents' families were contacted regarding the incidents. Staff 7 stated she was not asked to write a statement regarding the observed incident on the morning of 5/21/24 and was told to just make a progress note. Staff 7 stated nothing was in place regarding keeping Resident 15 and Resident 16 separated. - On 5/22/24 at 12:14 PM, Staff 6 (PT) stated on 5/19/24 she witnessed Resident 15 starting to lean into Resident 16 as if she/he was going to start kissing her/him. Staff 6 stated the residents were holding hands. Staff 6 stated Resident 16 had her/his right leg on the window seal with her/his legs open. Resident 15 had her/his other hand on Resident 16's groin area over the clothes. Staff 6 stated she wrote a statement, and it was given to administrative staff. Staff 6 stated she believed Resident 15 was able to understand to a certain extent. Staff 6 stated both residents kept seeking each other out. - On 5/21/24 at 12:40 PM and 5/22/24 at 12:59 PM, Staff 10 (CNA) stated she did not witness any of the incidents between Resident 15 and Resident 16 but was aware of the residents being caught together being intimate. Staff 10 stated she was not informed to keep both residents separated until Monday afternoon. - On 5/22/24 at 3:45 PM, Staff 15 (Social Services) stated he was not notified of the incidents between Resident 15 and Resident 16 until 5/21/24. Staff 15 stated it was initially the residents' holding hands, then kissing and touching. Staff 15 stated he spoke with Resident 15 and the resident indicated she/he was comfortable with the kissing, and it was ok. Staff 15 stated he spoke with Resident 16 using Google translate and the resident indicated she/he was also ok with the incidents. Staff 15 stated Resident 16's family was not contacted until 5/21/24 and was told the behavior had not been seen before to contact the family if it occurred again. Staff 15 stated he did not contact Resident 15's family but nursing staff did. Staff 15 stated he believed Resident 15 was her/his own responsible party and Witness 2 was power of attorney for financial only. Staff 15 stated if Resident 15 was able to let staff know when she/he had to use the bathroom she/he was then able to consent to the touching. Staff 15 further stated Resident 16 was cognitively able to consent but was just not able to communicate due language barrier. - On 5/22/24 at 4:31 PM, Staff 9 (RN) stated she was often the nurse for Resident 15. Staff 9 stated Resident 15 had dementia and was not able to consent to any relationship or sexual encounter. Staff 9 stated she did not directly see any of the sexual incidents occur but stated she overhead a conversation of administrative staff directing staff to put minimal information on the residents' progress notes regarding the incidents. - On 5/23/24 at 12:46, PM Staff 16 (LPN) stated she knew the incidents between Resident 15 and Resident 16 was sexual abuse. Staff 16 stated she informed Staff 1 that the incidents needed to be reported the state but was not. On 5/22/24 at 6:07 PM, Staff 1 (Administrator) and Staff 2 (Regional Director of Clinical) were notified of the Immediate Jeopardy (IJ) situation and provided a copy of the IJ template related to the facility's failure to implement policies and procedures to prevent sexual abuse resulting in witnessed repeated non-consensual sexual activity without appropriate assessments to determine consent and interventions in place. On 5/23/24 at 10:50 AM, an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: *An investigation for the interaction between Resident 15 and Resident 16 was to be completed. *Staff 1 was provided education regarding abuse and reporting of abuse on 5/22/24. Staff 1 was removed as the abuse coordinator pending completion of the investigation. *Care Plans for Resident 15 and Resident 16 were updated to identify sexual behaviors and interventions to prevent ongoing sexual interactions. Interventions included monitoring of residents to ensure they do not engage in sexual behaviors including kissing and fondling, and redirection away if attempts at sexual behaviors are observed. Additional intervention included immediate notification of charge nurse. Who would notify the DON (Director of Nursing) and administrator. *DON was to complete baseline interview audit of all cognitively intact residents to ensure there are no additional residents who have experienced non-consensual sexual contact. *DON would complete an interview audit of 15 staff members from various shifts and departments to ensure there has been no observed abuse in the past three months with cognitively intact and cognitively impaired residents. *DON was to provide education on active staff regarding abuse and reporting abuse. *Facility staff would be provided with information regarding who to contact if there was a lack of perceived response to reports of abuse from management at the facility level. *Audits would be conducted by DNS or designee weekly until substantial compliance was reached, then monthly for two months with verification of sustained compliance. *Audit trends would be reported to the facility QAPI for three months for review and further recommendations. *The Plan of Correction would be completed by 5:00 PM on 5/23/24. The IJ was removed on 5/28/24 at 3:58 PM, as confirmed by onsite verification by the survey team.

Based on interview and record review the facility administration failed to implement their abuse policy procedures in the areas of identification, investigation, protection, and reporting which resulted in repeated incidents of sexual abuse for 2 of 5 sampled residents (#s 15 and 16) reviewed for abuse. This failure to implement their abuse policy and procedures resulted in Resident 15 and Resident 16 repeatedly engaging in intimate nonconsensual sexual activity. The facility's 3/2023 Freedom from Abuse, Neglect and Exploitation policy including the Abuse Reporting and Responsibilities of Covered Individuals indicated the following: - The facility will provide a safe resident environment and protect residents from abuse . this includes freedom from . sexual or physical abuse. - Report allegation to appropriate authorities within required timeframes and conduct a thorough investigation. - Investigations of an allegation of sexual abuse will start with a determination of whether the sexual activity was consensual or not, taking into consideration the cognitive ability of the resident to consent. - To ensure alleged violations involving abuse, neglect, exploitation or mistreatment, are reported and the results of the investigation of the allegations are reported within the prescribed timeframes. - The facility will report to the State Agency and law enforcement any reasonable suspicion of a crime against any individual who is a resident or who is receiving care from the facility within timeframes. - In response to allegations of abuse .the facility will report immediately but no later than 2 hours, all alleged violations involving abuse . - The facility will create an environment in which staff and others feel comfortable and safe in reporting potential violations or suspicions of potential violations. Resident 15 admitted to the facility in 2019, with diagnoses including dementia. Resident 15's 2/16/24 Quarterly MDS indicated severe cognitive impairment. A Cognitive Evaluation completed on 5/21/24 indicated Resident 15 had moderate cognitive impairment. Resident 16 admitted to the facility in 2022, with diagnoses including stroke. Resident 16's 9/16/22 Admission MDS indicated severe cognitive impairment. A review of Resident 15 and Resident 16's progress notes from 5/19/24 through 5/20/24 revealed the following: - On 5/19/24 Staff 6 (PT) found Resident 15 in the common area touching Resident 16 inappropriately. Both the unit manager and administrator were notified. The note further indicated the encounter was investigated by management and the interaction was consensual. - On 5/20/24 at 11:19 AM Staff 7 (RN) found Resident 15 and Resident 16 in the dining room touching each other. Both residents were educated they could not do it there as it was a public place. The note indicated the administrator was aware. - On 5/20/24 at 5:50 PM Staff 8 (LPN) witnessed Resident 15 and Resident 16 in the front lobby. Both residents had their hands under clothing and touching groin and chest areas, kissing. The administrator was contacted. Staff 8 noted neither resident could not consent, and it was not the first time the behavior was witnessed. - On 5/20/24 at 7:44 PM Staff 8 indicated he spoke with Staff 1 (Administrator) and Staff 1 stated he investigated and ruled out abuse. Staff 8 indicated Staff 1 asked him if it was reported to the State. Staff 8 contacted Witness 3 (Resident 15's family) and informed him the administrator investigated the two previous incidents and ruled out abuse, per [Staff 1's] request. A review of Resident 15 and Resident 16's clinical record from 5/19/24 through 5/21/24 revealed the following: - No updated cognitive evaluation was completed for Resident 16. - Resident 15 and Resident 16's physician was not contacted until 5/21/24 and only indicated the one incident on 5/19/24. - No interventions were put in place to protect the residents from further incidents. - No thorough investigation was conducted related to the three incidents on 5/19/24 and 5/20/24. - No sexual consent assessment was completed for the residents. - No indication the State Survey Agency (SSA) was contacted until 5/21/24 at 3:42 PM, which only indicated the one incident on 5/19/24. Interviews conducted with facility staff revealed the following: - On 5/21/24 at 12:40 PM, Staff 12 (CMA) stated she was aware of Resident 15 and Resident 16 being found together two to three times. - On 5/21/24 at 1:14 PM, Staff 14 (CNA) stated she did not witness any of the incidents but was aware they were found together a few times. - On 5/21/22 at 1:46 PM, Staff 5 (LPN) stated on 5/19/24 a sexual incident between Resident 15 and Resident 16 was observed by Staff 6 (PT) and was reported to her. Staff 5 stated two more incidents between Resident 15 and Resident 16 occurred on the morning and evening of 5/21/24. Staff 5 stated Staff 8 (LPN) called Resident 15's family and was told by Staff 1 (Administrator) to not report the incident to the state. Staff 5 stated on 5/20/24 Staff 1 told staff to not worry about keeping the residents separate and the behavior was ok. - On 5/21/24 at 3:47 PM, Staff 8 stated on the evening of 5/21/24 he saw Resident 15 had her/hands under Resident 16's shirt and Resident 15 had her/his hand down Resident 16's pants, the residents were kissing. Staff 8 stated he asked staff what was going on and was told Staff 1 said it was ok for the behavior to occur. Staff 8 stated he looked in the progress notes and read the same type of incident had occurred twice before. Staff 8 stated he contacted both Staff 1 and the unit manager. Staff 8 stated Staff 1 asked if he had reported the observed incident to the state. Staff 8 stated he told Staff 1 it was his responsibility to notify the state. Staff 8 stated he contact Resident 15's family and was told by Staff 1 to inform the family two investigations had been completed and no abuse was determined. Staff 8 stated he was not asked to write a statement regarding the incident he observed. - On 5/22/24 at 11:32 AM and 5/23/24 9:47 AM, at Staff 7 (RN) stated on the morning of 5/21/24 she observed Resident 15 and Resident 16 in the dining room caressing each other. Staff 7 stated she was told by Staff 1 to direct the residents to a private area when the residents were observed engaging in intimate behaviors in public. Staff 7 stated she was not asked to write a statement regarding the observed incident on the morning of 5/21/24 and was told to just make a progress note. - On 5/22/24 at 12:14 PM, Staff 6 stated on 5/19/24 she witnessed Resident 15 starting to lean into Resident 16 as if she/he was going to start kissing her/him. Staff 6 stated the residents were holding hands. Staff 6 stated Resident 16 had her/his right leg on the window seal with her/his legs open. Resident 15 had her/his other hand on Resident 16's groin area over the clothes. Staff 6 stated she wrote a statement, and it was given to administrative staff. - On 5/21/24 at 12:40 PM and 5/22/24 at 12:59 PM, staff 10 (CNA) stated she did not witness any of the incidents between Resident 15 and Resident 16 but was aware of the residents being caught together being intimate. - On 5/22/24 at 3:45 PM, Staff 15 (Social Services) stated he was not notified of the incidents between Resident 15 and Resident 16 until 5/21/24. Staff 15 stated if Resident 15 was able to let staff know when she/he had to use the bathroom she/he was then able to consent to the touching. - On 5/22/24 at 4:31 PM, Staff 9 (RN) stated she was often the nurse for Resident 15. Staff 9 stated she did not directly see any of the sexual incidents occur but stated she overhead a conversation of administrative staff directing staff to put minimal information on the residents' progress notes regarding the incidents. - On 5/23/24 at 12:46 PM, Staff 16 (LPN) stated she knew the incidents between Resident 15 and Resident 16 was sexual abuse. Staff 16 stated she informed Staff 1 that the incidents needed to be reported the state but was not. - Staff 1 was not able to be interviewed due to being play on administrative leave pending facility investigation. - On 5/22/24 at 9:06 AM, Staff 2 (Regional Director of Clinical) acknowledged the sexual incidents between Resident 15 and Resident 16 was not reported to the State timely for the three identified incidents and stated she anticipated the citation. On 5/23/24 at 3:09 PM, Staff 17 (Regional Director of Clinical) was notified of the Immediate Jeopardy (IJ) situation and provided a copy of the IJ template related to the facility's failure to implement their abuse policy procedures in the areas of identification, investigation, protection, and reporting which resulted in repeated incidents of sexual abuse between Resident 15 and Resident 16. On 5/23/24 at 4:34 PM, an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: *Investigation for interaction between Resident 15 and Resident 16 was to be completed. *The 5/19/24 contact between Resident 15 and Resident 16 was reported to DHS on 5/21/24. * The Facility administrator was provided education regarding abuse and reporting of abuse on 5/22/24 and has been removed as the abuse coordinator pending completion of the investigation. * The Care Plans for Resident 15 and Resident 16 would be updated to identify sexual behaviors and interventions to prevent ongoing sexual interactions. Initial interventions were to include monitoring of resident(s) to ensure that they did not engage in sexual behaviors including kissing and fondling, and re-direction away if attempts at sexual behaviors such as touching or fondling were observed. Additional intervention included immediate notification of charge nurse, who would subsequently notify the DON and administrator. *The DON (Director of Nursing)/Designee would complete a baseline interview audit of all cognitively intact residents to ensure there were no additional residents who had experienced non-consensual sexual contact. *The DON/Designee would complete an interview audit of 15 staff members from various shifts and departments to ensure that there were no observations of abuse in the past 3 months with cognitively intact or cognitively impaired residents. *The DON/Designee would provide education to all scheduled and PRN staff not currently on a leave of absence on abuse and guidelines for reporting abuse. *Facility staff would be provided with information regarding who to reach out to at a higher management level if there is a perceived lack of response to reports of abuse from management at the facility level. *Audits would be conducted by DON or designee weekly until substantial compliance is reached, then monthly for 2 months with verification of sustained compliance. *Audit trends would be reported to facility QAPI for 3 months for review and further recommendations. *The Plan of Correction would be completed by 10:00 AM on 5/24/24. The IJ was removed on 5/28/24 at 3:58 PM, as confirmed by onsite verification by the survey team.

1. Based on interview and record review it was determined the facility failed to obtain treatment orders, failed to administer timely treatment, and failed to provided correct treatment for a surgical wound for 1 of 7 sampled residents (#6) reviewed for wounds. This failure, determined to be an immediate jeopardy situation, resulted in Resident 6 experiencing a delay in wound care treatment which resulted in the resident's wound to become infected and dehisced (separation of the wound due to improper healing). Resident 6 was re-hospitalized and required surgery for an above the knee amputation (AKA). Findings include: Resident 6 admitted to the facility on [DATE] with diagnoses of aftercare of the surgical right below the knee amputation and stroke. The 4/22/24 Admission Orders revealed no wound care orders for the right below the knee amputation (BKA). The 4/22/24 Skin Evaluation revealed the surgical wound measured 9.32 cm x 2.19 cm and had 30 staples. The wound was covered with xeroform (wound dressing) and kerlix (gauze wrapping) and the dressing was clean, dry and intact. There was no evidence in the medical record any staff from the facility clarified with the physician the lack of wound care orders or requested wound care orders until 4/29/24, seven days after the resident's admitted . On 4/29/24 wound care orders were received to cleanse the right stump with wound cleanser, pat dry, apply xeroform and an ABD (a gauze dressing that absorbs liquid from large, heavily draining wounds) and then wrap with kerlix and then an ACE wrap. This was to be completed every day. The 4/30/24 Skin Evaluation revealed the surgical wound measured 11.07 cm x 2.51 cm and indicated that no treatment was in place. The 4/2024 TAR revealed wound care to the right BKA was initiated on 4/30/24; eight days after admission to the facility. The 5/1/24 Progress Note revealed Resident 6's surgical wound staples were removed and replaced with steri-strips (strips of surgical tape used to close up wounds) and the right stump was redressed per treatment orders. The 5/2/24 Wound Consultant Note revealed Resident 6's wound measured 11.0 cm x 3.0 cm and had a scant amount of serosangenous exudate (bloody and yellowish liquid drainage from a wound). The 5/4/24 Progress Notes revealed Resident 6's wound dressing was saturated and removed. There were no steri strips on the wound, the wound edges were no longer approximated (close together) and the wound opened about an inch and a half. The resident was transferred to the hospital to be evaluated by a physician. The 5/4/24 Hospital Records revealed Resident 6's wound dehisced and there was concern of infection. The wound was irrigated (washed out), debrided (unhealthy skin removed) and a Wound Vac (Vacuum-assisted closure, a method to decrease air pressure around a wound to assist the healing) was applied. The 5/15/24 Hospital Discharge Summary revealed Resident 6 underwent a surgical right AKA on 5/7/24, three days after the resident was admitted . On 5/22/24 at 11:50 AM, Staff 4 (Unit Manager) acknowledged Resident 6 admitted to the facility with no wound care orders and did not receive any wound treatments from 4/22/24 through 4/30/24. Staff 4 stated if a resident admitted with a wound and no wound care orders, the staff should clarify and obtain the needed wound care orders. Staff 4 verified Resident 6's wound got infected, dehisced, and the resident was transferred back to the hospital where she/he had a right AKA. On 5/22/24 at 11:53 AM and 5/26/24 at 1:55 PM, Staff 19 (LPN) stated when she admitted Resident 6 to the facility she asked another staff member to obtain wound treatment orders since Resident 6 did not admit with any. Staff 19 further stated the wound got infected due to lack of wound care the first week and because Staff 21 (Former LPN) put calcium alginate (wound packing dressing used to absorb heavy drainage) all over the wound which caused the wound to deteriorate. Staff 19 stated she reported the calcium alginate incident to Staff 3 (DNS). On 5/22/24 at 1:34 PM, Staff 3 stated she could not recall when she was notified of the calcium alginate incident or how she responded. Staff 21 was unable to be interviewed. On 5/22/24 at 3:25 PM, Staff 1 (Administrator) and Staff 2 (Regional Director of Clinical) were notified of the Immediate Jeopardy (IJ) situation and provided a copy of the IJ template related to the facility's failure to obtain wound treatment orders, provide timely treatment to a wound and administer incorrect treatment. On 5/23/24 at 8:38 AM, an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: *Facility would verify wound treatments were in place for Resident 6. *A baseline audit of all residents to ensure there were no unidentified wound areas. *A baseline audit of residents with current wounds would be completed to ensure treatment orders were in place. *All licensed nurse staff would receive education regarding initiation of treatment orders for new admits with identified skim impairments and facility acquired skin impairments. *Weekly audits would be conducted for four weeks, then monthly for two months. *Audit trends would be reported to the facility QAPI for three months for review and further recommendations. *The Plan of Correction would be completed by 2:00 PM on 5/23/24. The IJ was removed on 5/28/24 at 3:58 PM, as confirmed by onsite verification by the survey team. 2. Based on interview and record review it was determined the facility failed to follow physician orders related to fluid restriction and wounds for 1 of 4 sampled residents (#20) reviewed for physician orders. This placed residents at risk for fluid overload. Findings include: a. Resident 20 admitted to the facility in 6/2022 with diagnoses including heart failure. The 4/12/24 Hospital Re-Admission Order's revealed an order to restrict fluids to 2,000 ml/day. The 4/21/24 through 5/20/24 Point of Care Fluid Intake documentation revealed Resident 20 exceeded her/his fluid restriction 21 of the 30 days reviewed. On 5/23/24 at 9:20 AM, Resident 20 declined to be interviewed. On 5/23/24 at 9:31 AM, Staff 22 (CNA) stated the resident did not follow the fluid restriction and consistently drank 1800 ml or more on day shift. Staff 22 stated she might remind the resident of the fluid restriction once a week. On 5/23/24 at 9:36 AM, Staff 20 (LPN) stated the resident was often not truthful about how much she/he drank and she did not report to the physician when she/he exceeded the fluid restriction. On 5/23/24 at 9:44 AM Staff 4 (Unit Manager) verified the facility did not follow the physician order for the 2,000 ml/day fluid restriction. 34324 b. Resident 18 admitted to the facility in 2018 with diagnoses including non-pressure chronic ulcers. A 5/4/24 physician order indicated Resident 18 was to receive wound care to the left lower extremity. Abrasions were to be cleansed with wound cleanser, xerofoam (wound dressing) was to be applied to the open areas, covered with an ABD pad (a gauze dressing that absorbs liquid from large or heavily draining wounds) and wrapped with Kerlix every other day. The 5/2024 TAR indicated the treatment to the left lower extremity was checked as completed on 5/18/24 by Staff 4 (RN Unit Manager). A progress note dated 5/19/24 indicated the dressing on the Resident 18's left lower extremity was not completed on 5/18/24. On 5/22/24 at 11:32 AM, Staff 7 (RN) stated she wrote the progress note on 5/19/24. Staff 7 stated Resident 18 was to receive dressing treatments every other day. Staff 7 stated on 5/19/24 she noticed the dressing was not changed for Resident 18 as the dressing had the date of 5/16/24 with her initials. On 5/23/24 at 11:14 AM, Staff 4 (RN Unit Manager) stated he worked the floor on 5/18/24 and was assigned to Wing 1 as the nurse. Staff 4 stated his duties as the nurse included completing treatments. Staff 4 stated he, did not get to those [treatments] on 5/18/24 due to being busy. Staff 4 acknowledged he did not complete the treatment for Resident 18 on 5/18/24 but marked it on the TAR as being completed. c. Resident 19 admitted to the facility in 2022 with diagnoses including a non-pressure chronic ulcer. A 5/2/24 physician order indicated Resident 19 was to receive daily wound treatments to the left foot. The wound was to be cleansed with wound cleanser, pat dried with collagen and wound gel applied. The 5/2024 TAR indicated the treatment to Resident 19's left foot was not completed on 5/17/24 and checked as completed on 5/18/24 by Staff 4 (RN Unit Manager). A progress note dated 5/19/24 indicated Resident 19 reported to Staff 7 (RN) her/his dressing to the left foot was not completed on 5/17/24 and 5/18/24. On 5/22/24 at 11:32 AM Staff 7 (RN) stated she wrote the progress note on 5/19/24 for Resident 19. Staff 7 stated Resident 19 was to receive daily wound treatments to the left foot. Staff 7 stated Resident 19's dressing still had the date of 5/16/24 with her initials. Staff 7 stated Resident 19 also informed her treatment was not completed. On 5/22/24 at 7:14 PM Resident 19 stated her/his treatment to the left foot was to be completed daily. Resident 19 stated her/his treatment was not completed on 5/17/24 and 5/18/24. Resident 19 stated Staff 7 noticed the treatment was not completed, and she/he told Staff 7 it was not completed. On 5/23/24 at 11:14 AM Staff 4 (RN Unit Manager) stated he worked the floor on 5/18/24 and was assigned to Wing 1 as the nurse. Staff 4 stated his duties as the nurse included completing treatments. Staff 4 stated he did, did not get to those [treatments] on 5/18/24 due to being busy. Staff 4 acknowledged he did not complete the treatment for Resident 19 on 5/18/24 but marked it on the TAR as being completed. On 5/23/24 at 12:46 PM Staff 16 (LPN/MDS Coordinator) stated she worked the floor on 5/17/24 and was assigned to Wing 1. Staff 16 stated her duties as the nurse included completing treatments. Staff 16 stated she did not complete the wound treatment for Resident 19 because the resident was up, and she did not want to interrupt the resident's social interactions. Staff 16 stated the treatment on the TAR for Resident 19 was left blank to alert the next nurse the treatment needed to be completed. Staff 16 acknowledged the treatment for Resident 19 on 5/17/24 was not completed. Staff 9 was unable to be interviewed.

Based on interview and record review it was determined the facility failed to comprehensively assess, monitor, treat and follow physician orders for pressure ulcer treatment for 1 of 7 sampled residents (#4) reviewed for pressure ulcers. This failure, determined to be an immediate jeopardy situation, resulted in Resident 4's Stage 2 (partial thickness skin loss) pressure ulcer observed upon admission which worsened to an infected, unstageable (full thickness tissue loss where the depth of the wound is obscured by non-viable or dead tissue) pressure ulcer. Resident 4 was admitted to the hospital where she/he required surgical debridement (the removal of damaged tissue from the wound). Findings include: Resident 4 admitted to the facility on [DATE] with diagnoses including heart failure, hemiplegia and non-pressure chronic ulcer of skin of other sites with necrosis (tissue death) of muscle. The 2/26/24 Admission Nursing Database indicated Resident 4 had multiple skin concerns including a pressure wound on the sacrum. The assessment further indicated the resident was confused and required extensive to total assistance by one to two staff members to turn and reposition in bed. The pressure ulcer assessment did not include measurements, staging, or characteristics of the wound. The 2/26/24 Admission Orders for Resident 4's sacrum wound included: cleanse with normal saline, pat dry, apply calcium alginate (wound dressing) to the wound bed and cover with foam daily. The 2/27/24 Progress Note revealed Resident 4 had a pressure ulcer on her/his sacrum. The 2/2024 TAR revealed no treatments were completed for Resident 4's sacrum wound from 2/26/24 through 2/29/24. The 3/2024 TAR revealed no sacral treatments were completed for Resident 4 from 3/1/24 through 3/6/24, until new orders were initiated on 3/7/24. The 3/11/24 Progress Note revealed eschar (nonviable tissue) and slough (dead tissue) were present on the sacrum wound. The 3/14/24 Pressure Ulcer Care Plan incorrectly documented the pressure ulcer as an unstageable [NAME] (pressure ulcer that arises within hours/days of death) Ulcer. The 3/20/24 Skin/Wound Evaluation revealed Resident 4's sacrum wound measured 4.91 cm x 3.17 cm x 2 cm. The assessment indicated the wound had deteriorated, was infected and assessed to be an unstageable ulcer due to slough and/or eschar. This was the first comprehensive wound assessment to include wound measurements, staging and wound characteristics. The 3/24/24 Progress Note indicated the sacrum wound continued to decline and the on-call provider was notified. The 3/27/24 Physician Note revealed the resident was referred to the wound clinic. The 3/28/24 Skin/Wound Evaluation revealed the sacrum wound measured 5.36 cm x 3.26 cm x 2.2 cm. The wound had deteriorated and there was evidence of infection. There was redness and inflammation around the wound, and light exudate (drainage) with moderate odor. The physician was notified. The 4/2024 TAR revealed no sacrum wound treatments were completed. The 4/2/24 Wound Consultant notes indicated on initial exam Resident 4's sacrum wound deteriorated with severe worsening. The 4/3/24 Skin/Wound Evaluation revealed the resident's wound measured 6.98 cm x 6.42 cm x 3.4 cm. The wound bed was 60% slough, had moderate drainage and a strong odor. The wound had deteriorated and the provider was notified. The 4/3/24 Progress Note revealed the resident had a change of condition related to blood in the urine and low blood pressure; the resident was transferred to the hospital. The 4/22/24 Hospital Records indicated Resident 4 was transferred to the hospital on 4/3/24 for blood in her/his urine and signs of infection in the sacrum wound. Resident 4 was diagnosed with an urinary tract infection, pneumonia and an infected sacral pressure ulcer with osteomyelitis (bone infection) which resulted in surgical debridement. Per the hospital records, after the surgical debridement the ulcer was identified as a Stage IV (full thickness skin loss) pressure ulcer. On 5/21/24 at 11:44 AM, Witness 5 (Previous Facility-Care Manager) stated Resident 4 discharged from their facility on 2/26/24 with a Stage 2 pressure ulcer to her/his coccyx with wound treatment orders. On 5/22/24 at 11:35 AM, Staff 4 (Unit Manager) verified the facility did not follow the admission physician wound care orders, did not treat the wound until 3/7/24, did not monitor or assess the wound until 3/20/24 and stopped treatment on 4/1/24. Staff 4 verified the facility incorrectly identified Resident 4's pressure ulcer as a [NAME] Ulcer. On 5/22/24 at 11:55 AM, Staff 19 (LPN) stated Resident 4's pressure wound was fist sized and she could smell the wound when she entered the room on 4/3/24. Staff 19 stated Resident 4's wound was not a [NAME] Ulcer. On 5/22/24 at 3:25 PM, Staff 1 (Administrator) and Staff 2 (Regional Director of Clinical) were notified of the Immediate Jeopardy (IJ) situation and provided a copy of the IJ template related to the facility's failure to assess, monitor and treat Resident 4's Stage 2 pressure ulcer and as a result worsened to a Stage 4 pressure ulcer. On 5/23/24 at 8:38 AM, an acceptable facility IJ removal plan was submitted by the facility. The plan indicated the facility would implement the following actions: *Resident 4 was discharged . *A baseline audit of all residents would be completed to ensure there were no unidentified wounds. *A baseline audit of residents verified to have current wounds will be completed to ensure treatment orders are in place. *A baseline audit will be completed of residents with current wounds to ensure there is a wound evaluation in place. *A baseline audit will be completed to verify residents with current wounds have care plan for skin impairment risk in place and identify interventions to promote skin integrity and wound healing. *Licensed nurse staff will be provided education regarding completing thorough evaluation on admission to identify areas of skin impairment. Education would identify the need to initiate treatment orders for new admissions with identified skin impairments as well as any newly identified facility acquired skin impairments. *Unit managers will be educated regarding the admit review process to include review for identified areas of impaired skin integrity and to verify treatment orders were initiated, and care plans were initiated based on skin risk factors. *Unit Managers will be educated regarding the completion of weekly wound evaluations. The DON/Designee will ensure the wound evaluations are completed weekly for residents who are identified as having wounds. *Audits will be conducted by DON or designee weekly for four weeks then monthly for two months. *Audit trends will be reported to facility QAPI for three months for review and further recommendations. The IJ was removed on 5/28/24 at 3:58 PM, as confirmed by onsite verification by the survey team.

Based on interviews and record review, it was determined the facility failed to ensure residents were free from verbal and physical abuse for 2 of 6 sampled residents (#s 13 and 17) reviewed for abuse. Resident 13 experienced psychosocial harm. Findings include: 1. Resident 13 admitted to the facility in 2023 with diagnoses including anxiety. A 1/11/24 Verbal aggression investigation indicated Staff 42 (Former CNA) was directed to shower Resident 13. Staff 42 escalated the volume of her voice yelling this is bullshit loudly which other residents could hear. Staff 42 stated to Resident 13 You're not taking forever to shower tonight. You get 15 minutes; I don't have time for this shit. Staff 40 (LPN) went to deescalate Staff 42 and remove her from the care of Resident 13. Staff 40 heard Resident 13 state You're hurting me. Staff 40 asked Staff 42 to leave and Staff 42 stated she would not leave and would be doing this fucking shower like you keep asking. Staff 42 started to quickly push Resident 13 toward the shower room in her/his wheelchair. Staff 42 was again directed to leave but she continued to push Resident 13 down the hallway and yell profanities. Resident 13 stated I don't know why you're so mad at me, I didn't do anything! Staff 42 told Resident 13 to knock it off while pushing the wheelchair to the shower room. Staff 42 continued to yell profanities and act irrationally. Resident 13's wheelchair then hit the wall when entering the shower room. Resident 13 yelled out you're hurting me. Staff 42 yelled I am not hurting you! aggressively to Resident 13. Staff 40 handed Staff 42 the phone to speak with the staffing coordinator and removed Resident 13 from Staff 42. Staff 40 closed the door to provide some sense of safety for Resident 13. Resident 13 was tearful and stated she/he did not know why Staff 42 was so mad taking her bad day out on her/him. Staff 42 then exited the shower room and was yelling as she entered multiple resident's rooms saying, this is the last time you will see me. This is my last day. I am sick of this shit. A 1/12/24 Alert Note indicated Resident 13 complained of lower back pain and requested an x-ray. No documentation was found in clinical records an x-ray was obtained for Resident 13's lower back pain. A 1/17/24 counseling Progress Note revealed Resident 13 was afraid and scared Staff 42 would return to the facility. Resident 13 reported she/he had to take pain medication to calm down and to stop hurting. Resident 13 reported she/he continued to think about the incident on several occasions, felt on edge, had intrusive memories, and was worried about being around other people. A 1/25/24 Nursing Note indicated Resident 13 requested her/his shower to be provided by Staff 44 (Unit Manager RCM). A 1/2024 Documentation Survey Report revealed Staff 44 provided Resident 13 a shower on 1/25/24 and 1/30/24. A 1/26/24 counseling Progress Note indicated Resident 13 reported having nightmares related to the incident and she/he was afraid to go past the shower room. A 2/1/24 counseling Progress Note indicated Resident 13 continued to experience fear and anxiety when she/he passed the shower room. On 2/15/24 at 12:19 PM Resident 13 stated Staff 42 (CNA) was angry because she could not take a her break and it was Resident 13's shower night. Resident 13 stated Staff 42 made all sorts of excuses and one of the nurses told her to give Resident 13 her/his shower. Staff 42 complained to Resident 13 she did not get her break and Resident 13 requested her to calm down because she/he felt Staff 42 was taking her anger out on her/him. Staff 42 told Resident 13 not to be so dramatic about it. Resident 13 stated Staff 42 pushed her/his wheelchair down the hall toward the shower room quickly. Resident 13 requested for Staff 42 to slow down, and she told her/him no she needed to get shit done. Staff 42 hit Resident 13's wheelchair into the wall in the shower stall and jolted Resident 13's back which hurt her/him. Resident 13 stated it felt like a semi-truck hit me. Resident 13 stated her/his back hurt for about a week and a half after the incident. On 2/15/24 at 2:24 PM Witness 4 (Complainant) stated Resident 13 continued to have acute stress response, fear, and anxiety about the shower room. On 2/21/24 at 10:34 AM Staff 42 indicated she pushed Resident 13 down the hall quickly and when they came to the shower room Resident 13 put her/his foot out and her/his foot hit the wall. Staff 42 stated Resident 13 started crying. Staff 42 stated she did not remember if she cussed but she did raise her voice. On 2/21/24 at 10:21 AM Staff 40 stated when she arrived at the facility and requested the plan for resident showers from the CNAs. Staff 42 stated I don't know if I have fucking time. Staff 40 requested Staff 42 to lower her voice in the hallway. When Staff 42 went to assist Resident 13 with her/his shower Staff 40 stated she heard Resident 13 state you're hurting me while in her/his room. Resident 13 was crying while being pushed down the hallway in her/his wheelchair. When Staff 42 turned the wheelchair into the shower room Staff 40 heard a bang and Resident 13 stated you're hurting me. Staff 42 stated I am not hurting [her/him]. After the incident Resident 13 complained of back pain. Staff 40 stated Resident 13's back pain lasted for a week or two and she/he was provided PRN pain medications. Resident 13 requested an x-ray, but no x-ray was completed. On 2/21/24 at 10:59 AM Staff 43 (Agency CNA) stated Resident 13 only allowed Staff 44 to complete her/his showers after 1/11/24. Staff 43 stated also after the incident she noticed Resident 13 did not sleep much and appeared sad. On 2/22/24 at 7:56 AM Staff 44 stated she continued to provide some showers for Resident 13 because she/he felt safe with Staff 44. Staff 44 stated abuse was not substantiated, but it was substantiated for lack of respect because the hitting the wall was accidental and the verbal aggression was toward staff members. On 2/22/24 at 10:10 AM Staff 1 (Administrator) stated the facility did substantiate for verbal abuse, Staff 42 was suspended during the investigation and was terminated when the investigation was completed. Refer to F699 2. Resident 17 admitted to the facility in 2023 with diagnoses including anxiety. Resident 18 admitted to the facility in 2023 with diagnoses including sepsis. A 11/24/23 Resident to Resident altercation investigation revealed Resident 18 was readmitted on [DATE] with sepsis and was aggressive to staff by trying to hit staff and was screaming at the nurses. Resident 17 observed Resident 18's bedside table was on her/his side of the privacy curtain and Resident 17 attempted to give Resident 18's bedside table back to her/him. Resident 18 grabbed Resident 17's right hand and slapped her/his hand three times. Resident 17 pulled back her/his hand and left the room to report to a staff member. On 2/15/24 at 1:34 PM Resident 17 confirmed the incident and reported no injuries or ongoing concerns from being slapped. On 2/21/24 at 10:07 AM Staff 30 (Former Social Services) reported Resident 18 readmitted to the facility on [DATE] and was hitting staff. Resident 17 reported to her on 11/24/23 when Resident 17 attempted to push Resident 18's bedside table back to her/him Resident 18 hit her/him three times and stated, get the fuck away from me. On 2/22/24 at 10:07 AM Staff 1 (Administrator) Stated she was not sure if the facility substantiated physical abuse or not. Staff 1 stated she would follow up. No additional information was provided.

Based on interview and record review it was determined the facility failed to provide pain medications as ordered for 3 of 3 sampled residents (#s 9, 59, and 144) reviewed for pain management. Resident 9 and 144 experienced severe pain. Findings include: 1. Resident 9 was admitted to the facility in 2023 with diagnoses including chronic pain, pain in the left shoulder, and brain cancer. An 10/2023 MAR instructed staff to provide one tablet of oxycodone (to treat moderate to severe pain) every four hours as needed for pain. On 10/30/23 it was documented Resident 9's pain level was a seven on a zero to 10 pain scale, and her/his first administration of the day was received at 12:03 PM. On 11/1/23 at 9:51 PM Staff 11 (RN) stated the internet and electronic clinical records for residents stopped working often. Staff 11 stated it was difficult to administer medications on 10/30/23 because of the outages. On 11/6/23 at 11:05 AM Staff 21 (CNA-Medication Technician) stated the facility was having difficulty with the internet and electronic clinical records. Staff 21 stated she could not administer medications as she did not know the resident's medicating dosing without the clinical record. Staff 21 stated the facility did not have another way to record and provide residents' medication when the internet or electronic records did not work. Staff 21 stated recently the morning nurse did not complete the administaion of all the medications for her assigned residents, so Staff 21 completed the administration of the morning nurse's medications as well as her own assigned medications. On 11/7/23 the following interviews occurred: -7:53 AM Staff 22 (CNA) stated on 10/30/23 Resident 9 requested her/his PRN pain medication four times, and after the last time she stated, Give me my pain medication or give me a gun. Staff 22 stated she let Staff 11 know and Staff 25 (LPN Unit Manager). -8:14 AM Resident 9 confirmed she/he stated to give her/him a gun because of the pain she/he was in on 10/30/23. Resident 9 stated her/his pain level at the time was about an eight and a half out of 10 on a scale of zero to 10. On 11/8/23 at 10:38 PM Staff 1 (Interim Administrator), Staff 2 (DNS), and Staff 3 (Regional Nurse Consultant) stated when the internet or the clinical records were not working for a while they printed the MARs and TARs for staff to complete medications through paper charting. 34703 2. Resident 144 was admitted to the facility in 2023 with diagnoses including cancer and chronic pain. An 10/25/23 Admission Evaluation indicated Resident 144 was alert to person, place, time, and situation. An 10/27/23 Pain Evaluation indicated resident 144 could not verbalize pain. On 10/30/23 at 3:15 PM Witness 9 (Family Member) stated Resident 144 did not receive pain medication besides Tylenol since admission, which did not work for cancer pain. Witness 9 stated nursing was notified multiple times. Resident 144 was painful and in tears but the staff did not notify the physician for stronger pain medication. Witness 9 stated the resident was on hydrocodone (pain medication) in the hospital and it worked for her/his pain. On 10/31/23 at 4:43 PM Resident 144 was observed lying in bed grimacing. A physician order dated 10/31/23 included oxycodone (pain medication) as needed. This was ordered five days after resident 144 was admitted . On 11/1/23 at 10:33 AM Resident 144 was observed lying in bed grimacing. Resident 144 stated she/he had pain but did not receive pain medication. Resident 144 became teary-eyed. On 11/05/23 at 12:42 PM Resident 144 was observed lying in bed grimacing and stated she/he was painful. On 11/6/23 at 4:09 PM Staff 5 (LPN) acknowledged the pain assessment was not accurate so the resident did not receive the pain medication needed. 36494 3. Resident 59 admitted to the facility in 2/2023 with diagnoses including pain and depression. A review of Resident 59's care plan updated 3/3/23, revealed the resident had chronic pain. Interventions included to monitor and report complaints of pain or requests for pain treatments, and to notify the physician if interventions were unsuccessful or if a current complaint was a significant change from Resident 59's baseline. The medical record revealed a physician's order dated 8/1/23 for oxycodone (narcotic pain medication) 10 mg, one tablet every six hours for cancer and sciatic (nerve) pain. A Nursing Note dated 8/8/23 at 4:26 PM revealed Resident 59 did not receive her/his pain medication all day, and a valid peerscription was needed to receive treatment. A message was left with the on-call provider and the facility was awaiting a call back. The resident was offered Tylenol to alleviate pain. A review of the 8/8/23 MAR revealed Resident 59 did not receive her/his 12:00 PM, 6:00 PM or 12:00 AM dose (12 hours later) of oxycodone. A Nursing Note dated 8/9/23 at 12:34 AM revealed the on-call provider was contacted again due to phone lines being down in the facility and the provider would send a new perscription for oxycodone to the pharmacy. The resident was notified and staff were to contact the pharmacy around 4:30 AM to obtain a pull-code for the Cubex (a medication dispenser) to administer the oxycodone. A review of Resident 59's Physician Orders dated 9/2023, revealed an order dated 9/2/23 for oxycodone 15 mg, give 0.5 tablet every six hours for chronic stomach pain and right arm pain. A nursing note dated 9/3/23 at 11:15 PM revealed Resident 59 missed her/his 6:00 PM dose of oxycodone as it was not available. Resident 59 complained of pain rated eight out of 10 to her/his back, right arm and leg due to missing the dose. A review of the 9/3/23 MAR revealed Resident 59 did not receive her/his 6:00 PM dose of oxycodone and Resident 59's pain was a nine out of 10. Resident 59 did not receive her/his next dose until 9/4/23 at 12:00 AM (six hours later) and her/his pain was nine out of 10. On 10/30/23 at 1:24 PM Resident 59 stated her/his pain medications were not always given timely and could make her/him uncomfortable and frustrated. On 11/2/23 at 10:13 PM Staff 44 (RN) stated she was not aware of the 8/2023 incident but remembered the 9/3/23 incident and Resident 59 missed a dose of her/his oxycodone. Staff 44 stated Resident 59 had chronic pain and her/his pain level was typically around seven or eight out of 10 at baseline. Staff 44 stated the 9/3/23 incident occurred on a weekend and the facility struggled with ensuring medications and narcotic medications were re-ordered timely. Staff 44 stated she typically tried to request medications when the resident was down to five or seven narcotic pills. On 11/8/23 at 11:15 AM Staff 50 (Nurse Practitioner) stated the facility struggled with re-ordering pain medications and was an ongoing issue and concern of hers. Staff 50 stated staff waited too long to re-order or let the prescription expire. Staff 50 stated she had to write a new prescription which was sent to the pharmacy to be processed before the residents could receive their medications. On 11/8/23 at 12:05 PM Staff 2 (DNS) stated staff were expected to submit a request to the pharmacy when a resident's narcotic medication card had seven or eight pills remaining on the card. Staff 2 stated if a whole new prescription was needed the facility staff could reach out to the provider or the pharmacist. On 11/8/23 at 1:07 PM Staff 48 (Pharmacy Director) stated if the facility needed a new prescription or a prescription was soon to expire, the facility staff would need to request three or four days in advance to allow the pharmacist time to receive a new prescription from the provider in order to fill the new medication prescription.

Based on observation, interview and record review the facility failed to provide medically related social services to attain or maintain the highest practicable mental, and psychosocial well-being for 1 of 7 residents (#9) reviewed for physical environment. Resident 9 experienced a decline in depressed mood, social patterns and loss of pleasure. Findings include: Resident 9 was admitted to the facility in 7/2019 with a diagnosis including [CONDITION(S)], contracture of left lower leg, and [CONDITION(S)] of both knees. A 7/9/19 Care plan indicated Resident 9 was limited in physical mobility with a goal to remain free of complications related to immobility, and interventions including the use of a powered wheelchair for locomotion. A 9/10/19 Social Services Note indicated there were questions regarding new electric wheelchair and social services was to contact the caregiver about the status of the new wheelchair. A 9/24/19 Social Service Note indicated on 9/30/19 there was an appeal call with social services to discuss the status for Resident 9's a new electric wheelchair. No documentation was found in the clinical records related to a temporary electric wheelchair for Resident 9, what the definition of what the appeal call was or an assessment for proper fit of the the wheelchair. An 10/2/19 Social Service Note indicated the appeals call was rescheduled. No documentation was found for when it was rescheduled or if it was for Resident 9's electric wheelchair status. A 7/16/20 Annual MDS revealed Resident 9 had difficulty with falling asleep, staying asleep or sleeping too much, feeling tired, had poor appetite, or over ate with a severity score of four (a summary of the frequency scores which indicates the extent of potential depression symptoms). Resident 9 did not have behaviors of rejection of care. A 11/6/20 Social Service Note indicated an agency was coming out sometime to fix Resident 9's electric wheelchair. A 12/21/20 public complaint was received Resident 9's wheelchair was broken and the facility was not assisting in helping to fix the wheelchair. A 1/15/21 Social Service Note indicated social services was working on getting Resident 9 a new electric wheelchair. A 2/10/21 Psychology Progress Note revealed Resident 9 seemed to have worsening mental health symptoms. Resident 9 spoke mainly about issues coping with her/his situation. Resident 9 reported she/he spoke with a staff person and found out it was the motor on her/his electric wheelchair and the facility was working on a solution. Resident 9 described how she/he sat in a regular wheelchair on 2/9/21 and experienced shooting pain in her/his right arm. Resident 9 described feeling extremely depressed due to worry about declining physical and mental health. Resident 9 explored how laying in bed most of the day was starting to bother her/him. A 2/23/21 Psychology Progress Note revealed Resident 9 focused on tasks she/he would like to complete. Resident 9 stated There are things I need to do out of bed. Resident 9 described feeling stuck because her/his electric wheelchair continued to need repairs. A 2/24/21 Social Service Note indicated social services was still attempting to get Resident 9 a new electric wheelchair. Resident 9 was willing to pay for a new electric wheelchair on her/his own and a lady at the company for electric wheelchairs informed Witness 25 (Former Social Services Director) private pay was accepted unless there was a refusal from Resident 9's insurance company first. The note also indicated the facility broke Resident 9's electric wheelchair months ago and the facility was responsible for getting her/him a new electric wheelchair. Witness 25 indicated in the note Resident 9's mental health was deteriorating without an electric chair because she/he could not maneuver herself/himself. A 2/24/21 Social Service Note indicated Witness 25 spoke to the electric wheelchair company and an electric wheelchair would be ordered and the insurance would pay for the electric wheelchair if Resident 9 was at a foster home or an assisted living home. A 3/29/21 Social Service Note indicated a CNA came to social services to request social services to speak with Resident 9 as she/he was crying and upset about not being able to leave the facility. Resident 9 stated she/he was rotting away in her/his bed. Resident 9 stated she/he wanted to get up into a chair and did not care which chair. Witness 25 stated the facility was working on getting a new electric wheelchair, but she/he needed to discharge from the facility. Resident 9 continued to cry the entire conversation and Witness 25 reassured her/him the facility was doing everything the facility could to help. A 7/15/21 Annual MDS indicated Resident 9 was feeling down, depressed, or hopeless, difficulty with falling asleep, staying asleep or sleeping too much, feeling tired and moving or speaking slowly or fidgety or restless with a severity score of 11. A 7/20/21 Social Service Note indicated multiple staff mentioned Resident 9 wanted to fall asleep and never wake up. A 7/19/21 ADL CAA indicated Resident 22 was at risk for decline in ADL self-care performance functions with risks associated with ADL deficits included loss of dignity, inability to meet personal needs, depression, and apathy. Staff were to aid Resident 9 to ensure her/his needs were met. An 10/15/21 Quarterly MDS indicated transfers only occurred once or twice and Resident 9 required two-person physical assist and did not exhibit rejection of care behaviors. Resident 9 had little interest or pleasure in doing things, feeling down, depressed, or hopeless, difficulty with falling asleep, staying asleep or sleeping too much, feeling tired, trouble concentrating on things, moving, or speaking slowly or fidgety or restless, poor appetite or overeating and thought that she/he would be better off dead or hurting self in some way with a severity score of 13. On 1/25/22 at 1:47 PM Resident 9 was observed in bed in her/his room. Two electric wheelchairs were at the foot of Resident 9's bed. One appeared as a larger older model electric wheelchair with personal items stacked on top. A second smaller electric wheelchair was next to the larger electric wheelchair. On 1/27/22 at 9:26 AM and 12:09 PM Resident 9 was observed in bed in her/his room. Resident 9 stated she/he spent about a month in bed because there was a lack of staff. Resident 9 stated she/he would love to get up out of her/his bed if her/his electric wheelchair was functioning. Resident 9 stated the replacement electric wheelchair which was provided by the facility was too uncomfortable to sit in. On 1/31/22 at 11:06 AM Witness 8 (Complainant) stated Resident 9's electric wheelchair was her lifeline for getting out of bed. Staff reported the electric wheelchair could not be fixed and mentioned getting a new electric wheelchair, but it was not done. Resident 9 could not use a regular wheelchair as she/he slid out of it. Resident 9 reported to Witness 8 she/he feel stuck there at the facility. On 2/3/22 at 1:36 PM Witness 25 stated Resident 9 informed her in 10/2020 facility staff broke her/his electric wheelchair in 2019 while transferring her/him with a mechanical lift. The replacement wheelchair provided a few months after her/his electric wheelchair was damaged, was a temporary solution but it was uncomfortable for Resident 9 and not suitable for her/him. Witness 25 stated Resident 9 was a very social person and liked to venture out on her/his own but did not like the temporary electric wheelchair because it was so uncomfortable. Resident 9 went on outings and came back in a lot of pain because the electric wheelchair caused her/him pain. On 2/4/22 at 11:18 AM Staff 11 (CNA) stated it was a long time from the time Resident 9's electric wheelchair broke and when she/he received a replacement. Staff 11 stated he thought it was in 2021 when she/he received a replacement electric wheelchair. On 2/7/22 at 8:50 AM Staff 10 (Social Services Assistant) stated she did not know what was going on with Resident 9's electric wheelchair. Staff 10 spoke with Resident 9 about her/his bills but not her/his electric wheelchair. Staff 10 stated Resident 9 did not look comfortable in her/his temporary wheelchair. On 2/9/22 at 2:31 PM Staff 13 (CNA) stated he worked with Resident 9 for about a year and for a while Resident 9 got out of bed to go on outings and was up more frequently. Staff 13 stated the temporary electric wheelchair was painful for her/him to sit in. Staff 13 stated he noticed Resident 9 was increasingly more anxious than before. On 2/14/22 at 12:55 PM Resident 9 was observed in bed in her/his room with two electric wheelchairs at the foot of the bed. A 2/17/22 Psychologist Summary and Diagnosis revealed Resident 9 reported a recent history of depressive episodes related to decline in independence and increased medical issues. Resident 9 reported a range of stressors which included issues with not having an usable electric wheelchair. In an interview on 2/16/22 at 11:08 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 56 (Regional Nurse Consultant) stated there were insurances issues related to Resident 9's electric wheelchair and Staff 1 stated she was not aware the temporary electric wheelchair was uncomfortable for Resident 9.

Based on the lack of effective systems for ensuring the provision of medically related social services, adequate staffing levels, adequate staffing competencies, the facility administration failed to utilize its resources effectively and efficiently to ensure all residents attained or maintained their highest practicable physical, mental and psychosocial well-being. These failures resulted in Resident 9 experiencing psychosocial harm. These failures also placed residents at risk for delayed care, lack of awareness of resident rights. Findings include: 1. Deficient practice was identified regarding the facility's failure to provide medically related social services. This failure resulted in Resident 9 experiencing psychosocial harm. In an interview on 2/16/22 at 11:08 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 56 (Regional Nurse Consultant) stated the facility was attempting to hire a Social Services Director and the Unit Managers were assisting with some of the tasks. Refer to F745 2. Deficient practice was identified regarding the facility's failure to ensure adequate RN and CNA staffing. In an interview on 2/16/22 at 11:08 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 56 (Regional Nurse Consultant) stated it was difficult to fill staff positions. Refer to F725 and F727 3. Deficient practice was identified regarding training for agency staff resulting residents experiencing neglect, lack of dignity and risk for accidents. In an interview on 2/16/22 at 11:17 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 56 (Regional Nurse Consultant) stated it was difficult to obtain some of the documentation from the outside agencies for their temporary staff members and the expectation was for all temporary staff to have orientation and training. Refer to 550, 600, 689 and 727

Based on interview and record review it was determined the facility failed to ensure residents did not develop avoidable pressure ulcers for 1 of 5 sampled residents (#39) reviewed for pressure ulcers. Resident 39 developed multiple Stage 2 pressure ulcers (partial thickness skin loss) Findings include: Resident 39 was admitted to the facility in 6/2019 with [DIAGNOSES REDACTED]. A 6/6/19 Nursing Admission Evaluation indicated the resident admitted with a left knee brace. A review of the 6/2019 TAR indicated staff began monitoring of the skin under the left knee brace twice daily on 6/12/19, six days after the resident admitted with the brace. The documentation related to this entry revealed the following: 15 times = i nine times = + six times = off five times = - one time = b one time = 2 one time = 6 There was no further documentation or a legend to verify what the various symbols, numbers and letters indicated. A review of progress notes from 6/2019 did not reveal any information related to the TAR entries for skin monitoring of the left leg. A 6/16/19 progress note revealed Resident 39 suffered a new injury to the right knee while in the facility and now required a brace to be worn on the right leg as well as the left. A 6/19/19 progress note revealed red spots were found on the inner knees and ankles of both legs and blue hospital pants were placed under the braces to protect the resident's skin. The investigation related to the resident's skin injuries revealed on 6/19/19 therapy informed the charge nurse of multiple pressure ulcers on the resident's legs. Assessment of the resident revealed the following: *Stage 2 pressure injury to right medial thigh *Stage 2 pressure injury to right knee *Stage 2 pressure injury to right shin *Stage 1 pressure injury to left medial thigh *Stage 2 pressure injury to left shin *Stage 2 pressure injury to left knee The resident's care plan was revised on 6/20/19 and indicated the resident had multiple pressure ulcers on both legs related to the use of braces. Instructions added to the care plan after the pressure ulcers were found instructed staff not to place the braces onto bare skin. Prior to 6/20/19 the care plan did not include any information related to the management or application of the braces. On 8/19/19 at 1:50 PM Staff 10 (RN Unit Manager) reported the braces were placed on Resident 39's legs without anything between them and the resident's skin. She further stated the braces were not intended to be placed on bare skin. Staff 10 reported when the resident's wounds were assessed it was clear the origination was pressure and the wounds aligned with the contact points of the braces. She confirmed there was nothing on the care plan to instruct staff on how to place the braces on the resident prior to the pressure ulcers being found. On 8/21/19 at 10:40 AM Staff 10 confirmed there was no skin monitoring in place on the TAR for the right leg until after the pressure injuries were noted. She further verified there was not a legend associated with the TAR entry for the left leg skin monitoring. Staff 10 reported there were multiple different responses on the TAR and she did not know what they all meant.

Based on observation, interview and record review it was determined the facility failed to ensure [MEDICAL TREATMENT] (process to remove wastes from the body) services were appropriately provided for 1 of 1 sampled resident (#65) reviewed for [MEDICAL TREATMENT]. Resident 65 required emergent [MEDICAL TREATMENT] treatment at the hospital after missing outpatient treatments. Findings include: a. The facility's Clinical Services Policy and Guidelines for [MEDICAL TREATMENT] care included the following information: Policy: The facility will provide residents who require [MEDICAL TREATMENT] care and service consistent with professional standards of practice, a comprehensive person-centered care plan, and inclusive of the residents' goals and preferences. Guidelines: 1. The facility will provide or collaborate with a provider for the provision of [MEDICAL TREATMENT] services. 2. The nursing home must inform each resident before or at the time of admission, and periodically thereafter during the resident's stay, of [MEDICAL TREATMENT] services, if available in the nursing home. 3. Ongoing assessment of the resident's condition and monitoring for complications before and after [MEDICAL TREATMENT] treatments received at a certified [MEDICAL TREATMENT] facility; and communicates and collaborates on the resident's [MEDICAL TREATMENT] care plan between the facility and the [MEDICAL TREATMENT] treatment center. 4. For a resident receiving [MEDICAL TREATMENT], the nursing home staff will contact and communicate with the attending physician/practitioner, resident/resident representative, and designated [MEDICAL TREATMENT] staff regarding any significant changes. Resident 65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 6/14/19 Discharge Summary indicated Resident 65 had a CVC (central venous catheter - tubing placed directly into a vein), required [MEDICAL TREATMENT] every other day, transportation was a potential concern, to ensure the skilled nursing facility placed a transfer sling under the resident for transfers and the resident needed [MEDICAL TREATMENT] on 6/15/19 whether she/he was still in the hospital or as an outpatient after discharge to the skilled nursing facility. Progress notes on 6/14/19 and 6/15/19 revealed: - 6/14/19 at 5:55 PM: Resident 65 was admitted to the facility and noted to have a left [MEDICAL TREATMENT] port. - 6/15/19 at 12:51 PM: Resident very lethargic but able to make needs known. - 6/15/19 at 1:00 PM: Resident had an unwitnessed fall and bouts of being lucid but remained confused for most of the day. - 6/15/19 at 3:36 PM: Resident was informed earlier in the day she/he had a [MEDICAL TREATMENT] appointment at 10:30 AM. The progress note further indicated transport arrived to take her/him, then returned approximately one hour later and said her/his appointment was at 6:30 PM and she/he would receive the treatment at the hospital. Staff documented the [MEDICAL TREATMENT] center was called twice and they were unable to leave a message. Resident 65 did not receive a [MEDICAL TREATMENT] treatment as ordered following her/his discharge from the hospital and there was no documented evidence the physician was notified and the resident was not taken to the hospital on [DATE]. Progress notes from 6/16/19 through 6/18/19 revealed: - 6/16/19 at 4:43 PM: Staff talked with after hours infusion services but were unable to verify upcoming [MEDICAL TREATMENT] appointments and indicated follow-up was required on Monday 6/17/19. - 6/17/19 at 9:10 AM: Social Services documented planning for [MEDICAL TREATMENT] appointments on Tuesday, Thursday and Saturday and transport was being set up. - 6/18/19 at 8:10 AM: [MEDICAL TREATMENT] was planned for that evening at 6:00 PM. - 6/18/19 at 9:28 PM: Resident 65's son was notified the facility was instructed to send the resident to the emergency room (ER) for emergent [MEDICAL TREATMENT]. - 6/18/19 at 9:33 PM: The note indicated Resident 65's transportation to [MEDICAL TREATMENT] never showed up. The transport company was notified and sent a vehicle which was unable to accommodate the resident. Staff notified the [MEDICAL TREATMENT] center who indicated the resident missed three [MEDICAL TREATMENT] sessions and needed to go to the ER for [MEDICAL TREATMENT] that night. The note further indicated the center had no appointments available on 6/19/19. Resident 65 was sent to the ER at 8:00 PM. Admission notes from the hospital on [DATE] at 8:39 PM revealed Resident 65 was admitted with [MEDICAL CONDITION] (high potassium level) from missing [MEDICAL TREATMENT] and was emergently dialyzed. The resident's potassium level at the time of admission was 6.4 (normal: 3.5-5.1), according to the National Kidney Foundation a potassium level higher than 6.0 is in the danger zone (requires immediate treatment). A 6/19/19 hospital progress note indicated Resident 65 did not receive her/his outpatient [MEDICAL TREATMENT] treatments due to transportation issues or miscommunication between the skilled nursing facility and the [MEDICAL TREATMENT] center. The resident did not receive [MEDICAL TREATMENT] between 6/14/19 through late in the day on 6/18/19. A 6/20/19 progress note revealed Resident 65 returned to the facility after she/he missed three [MEDICAL TREATMENT] treatments and required hospitalization for emergent treatment. During an interview on 8/20/19 at 2:31 PM Staff 3 (RN Unit Manager) acknowledged Resident 65's missed appointments and need for emergency [MEDICAL TREATMENT] after admission. Staff 3 indicated she did not know whether the physician was notified at the time and would look for additional information. On 8/20/19 at 4:00 PM Staff 3 stated she was unable to locate additional documentation for the resident's missed [MEDICAL TREATMENT] treatments. Staff 3 indicated when something like that occurred staff should notify alternate providers and supervisors. Staff 3 stated she would look for lab work or other documentation that may have been requested. No additional information was provided. b. Resident 65's care plan revealed [MEDICAL TREATMENT] interventions dated 6/27/19 including monitoring the access site for signs of infection and change dressing per MD/protocol, monitor labs and intake and output and watch for [MEDICAL CONDITION]. The care plan indicated the resident required extensive assistance of two staff during showers. On 6/26/19 a progress note revealed the resident's [MEDICAL TREATMENT] CVC access site was found covered with a 4 x 4 gauze dressing with paper tape. The note indicated the dressing was changed and the area around the insertion site appeared red. On 6/27/19 a progress note indicated the [MEDICAL TREATMENT] center was contacted regarding the dressing over Resident 65's access site. Facility staff asked [MEDICAL TREATMENT] to leave dressing alone to be maintained by the facility with a more sterile dressing procedure and use of an occlusive (air and water tight) dressing. The nurse at [MEDICAL TREATMENT] indicated that was against their policy and refused to use the facility's dressing protocol. A second progress note on 6/27/19 revealed Resident 65 returned from [MEDICAL TREATMENT] with a 2 x 2 gauze dressing. Facility staff removed the dressing and replaced it with an occlusive dressing. A 6/30/19 progress note revealed the [MEDICAL TREATMENT] center continued to change the dressing to gauze and tape despite requests to leave intact for facility to maintain. On 7/5/19 the physician documented regarding the CVC dressing: no occlusive dressing after the first seven days of placement. (MONTH) reinforce tape and gauze as needed. On 8/5/19 the care plan was updated for the access site dressing to be changed at [MEDICAL TREATMENT] and [MEDICAL TREATMENT] treatment days were added with a note to ensure the transfer sling was under the resident for transfers. On 8/7/19 at 9:56 AM Resident 65 indicated her/his [MEDICAL TREATMENT] was located on the upper left side of her/his chest. The gauze dressing was observed to be clean, dry, intact and dated 8/6/19. On 8/9/19 at 11:09 AM Resident 65 was observed in a wheelchair in her/his room and stated she/he was given a shower and the dressing over her/his left upper chest [MEDICAL TREATMENT] port got wet and came off. The resident further stated she/he called for assistance several times and no nurse came to take care of the dressing. The dressing was still wet and lying on top of the access site where the resident replaced it after it came off. In an interview on 8/12/19 at 3:21 PM Witness 1 (RN [MEDICAL TREATMENT] Coordinator) confirmed the facility wanted to use a non-permeable dressing over the [MEDICAL TREATMENT] and it was against their policy because they can create moisture at the insertion site. Witness 1 stated a resident with a CVC catheter should never be showered and instructions with policies and procedures were provided when the resident began treatment. On 8/19/19 at 4:12 PM Staff 41 (CNA) stated Resident 65 preferred a bed bath but it was not in her/his care plan and therapy did most of her/his showers. On 8/20/19 at 9:29 AM Staff 47 (Director of Rehab) stated Resident 65 received a shower as part of OT and would likely receive another one before she/he went home. During an interview on 8/20/19 at 2:31 PM Staff 3 (RN Unit Manager) stated she was aware of some issues with the Resident 65's access site dressing but was not aware the dressing got wet and came off during a shower. Staff 3 further stated she did not know about policy of no showers or other [MEDICAL TREATMENT] policies and procedures and indicated she needed to request them.

Based on interview and record review it was determined the facility failed to ensure Staff 6 adhered to professional standards of practice to initiate CPR (cardiopulmonary resuscitation) for 1 of 4 sampled residents (#12) reviewed for CPR. This failure, determined to be a past non-compliance immediate jeopardy situation, resulted from Staff 6 failing to initiate CPR for Resident 12 when the resident was found with no heartbeat or respirations. Resident 12 did not have an advance directive in place. Findings include: Oregon Administrative Rule 851-¿045-¿0070 Conduct Derogatory to the Standards of Nursing Defined included: Failing to take action to preserve or promote the client's safety based on nursing assessment and judgment. Resident 12 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. No Advanced Directive was found in Resident 12's clinical record. Resident 12's Face Sheet in the facility's electronic clinical record revealed Resident 12's code status was blank with no information entered. A [DATE] Nurses Note revealed Staff 8 (CNA) approached Staff 6 (LPN) at 6:32 AM and advised Staff 6 Resident 12 was not breathing. Staff 6 evaluated Resident 12 and she/he did not have a pulse or respirations present. Staff 6 notified Staff 4 (RN Charge Nurse) who called EMS. The crash cart (emergency equipment for life support) was retrieved and CPR was started as per protocol. EMS arrived at approximately 6:50 AM. A [DATE] Nurses Note revealed Staff 6 approached Wing 4's nurses station searching for the crash cart and stated a resident was dead and needed the cart to perform CPR. Staff 2 asked if CPR was initiated and Staff 6 stated no. The time was approximately 6:58 AM. On [DATE] at 11:01 AM Staff 4 stated Staff 6 approached her between 6:30 AM and 6:40 AM and reported Resident 12 was dead. Staff 4 stated to Staff 6 she thought Resident 12 was full code (need to initiate CPR). Staff 4 stated to Staff 6 she needed to do CPR. On [DATE] Staff 2 (LPN) stated Staff 6 approached the nurses station and inquired where the crash cart was located. Staff 2 stated Staff 6 explained to her a resident was dead and CPR needed to be initiated. Staff 2 and Staff 54 (LPN) obtained the crash cart and ran down the hall to Resident 12's room. Staff 6 stated they did not need to run as Resident 12 had been dead a while. On [DATE] Staff 6 (LPN) stated a CNA approached her about 6:30 AM and stated she thought Resident 12 was dead. Staff 6 assessed Resident 12 and she/he had no vital signs and Staff 6 felt the resident was dead for a while. Staff 6 stated she went to Staff 4 who checked the advance directive book (to determine if CPR was initiated for residents) Staff 4 stated Resident 12 did not have an advance directive so CPR needed to be started. Staff 6 stated she went to the other nurse's station and asked about the crash cart. When Staff 2 and Staff 54 ran down the hall toward the room, Staff 6 stated they did not need to run as Resident 12 had been dead a while. A [DATE] Investigation revealed on [DATE] the following occurred: -Staff 8 (CNA) found Resident 12 not breathing at approximately 6:20 AM. Staff 8 ran to Wing 2 nurses' station, informed Staff 6 and she stated I got it from here if I need help I will ask you. -Staff 4 reported on [DATE] between 6:30 AM and 6:40 AM Staff 6 approached her and stated Resident 12 was unresponsive. Staff 4 informed Staff 6 Resident 12 was a full code. Staff 4 and Staff 6 went into the room and after Staff 4 observed Resident 12 she went to call 911 as Staff 6 went to obtain the crash cart. -Staff 9 (CNA) stated Staff 6 did not know where the crash cart was located. -Staff 54 stated he saw an older nurse waking down the hall with a crash cart at a slow pace. Staff 54 asked what happened and after Staff 6 informed him, he ran to the room to initiate CPR. -Staff 1 (Administrator) stated she received a call at 6:46 AM stating Resident 12 was dead. During a second call at 7:00 AM Staff 1 was informed CPR was initiated before the 6:46 call was ended. -Staff 4 stated at approximately 6:50 AM Staff 6 inquired where the crash cart was located and reported CPR was not yet started. Staff 6 reported at approximately 6:30 AM Staff 8 informed her Resident 12 needed to be seen right away. The report revealed licensed nurses were re-educated on [DATE] related to CPR policy, code status and the running of a mock code. A [DATE] Performance Improvement Action Plan revealed the following: -Re-education provided to nurse staff on CPR policy, presumptive and irreversible signs of death and code status. -Validate and verify code status in clinical record of current residents. -Validate licensed nurses CPR certification. -Chart review of residents who expired in last 30 days to verify advance directive followed. -Mock codes implemented monthly. -Code status reviewed weekly for four weeks then monthly thereafter. -CPR certification of licensed nurses reviewed monthly. -Chart review of expired residents completed to verify advance directive weekly for four weeks. -Audit trends presented for review at Quality Assessment and Assurance for further recommendations. On [DATE] at 2:22 PM Staff 37 (Regional Nurse Consultant) confirmed Resident 12 was not administered CPR timely as required and the facility initiated a plan of correction and provided training to the staff due to the concern. On [DATE] at 2:23 PM Staff 37 was informed of the past non-compliance Immediate Jeopardy. Refer to F678.

Based on interview and record review it was determined the facility failed to perform CPR (cardiopulmonary resuscitation) on a resident found with no heartbeat and not breathing for 1 of 3 sampled residents (#12) reviewed for CPR. This failure, determined to be a past non-compliance immediate jeopardy situation, resulted from the facility failing to initiate CPR for Resident 12 when the resident was found with no heartbeat or respirations. Resident 12 did not have an advance directive in place. Findings include: A ,[DATE] Clinical Services Policy and Guidelines for Implementation Quality of Life Cardio-Pulmonary Resuscitation (CPR) revealed the following: -The facility will provide basic life support, including CPR, to a resident while awaiting the arrival of emergency medical personnel in accordance with physician orders [REDACTED]. -Upon admission, staff will verify the presence of advance directives or the resident's wishes with regards to CPR. Resident's wishes may be communicated through the resident representative. -Resident wishes would be maintained in the electronic health record to inform staff of resident wishes. -Licensed nursing staff will maintain a current CPR certification. Training will include hands-on practice and skills assessment. -When cardiac or respiratory arrest occurs, facility staff will initiate basic life support and CPR for residents who do not show obvious clinical signs of irreversible death and who have requested CPR in their advance directives, or who have not formulated an advance directive, or do not have a valid do not resuscitate (DNR) order. -Basic life support and CPR will continue until emergency medical services (EMS) arrive to assume care for the resident. Resident 12 was admitted to the facility in ,[DATE] with [DIAGNOSES REDACTED]. No Advanced Directive was found in Resident 12's clinical record. Resident 12's Face Sheet in the facility's electronic clinical record revealed Resident 12's code status was blank with no information entered. A [DATE] Nurses Note revealed Staff 8 (CNA) approached Staff 6 (LPN) at 6:32 AM and advised Staff 6 Resident 12 was not breathing. Staff 6 evaluated Resident 12 and she/he did not have a pulse or respirations present. Staff 6 notified Staff 4 (RN Charge Nurse) who called EMS. The crash cart (emergency equipment for life support) was retrieved and CPR was started as per protocol. EMS arrived at approximately 6:50 AM. A [DATE] Nurses Note revealed Staff 6 approached Wing 4's nurses station searching for the crash cart and stated a resident was dead and needed the cart to perform CPR. Staff 2 asked if CPR was initiated and Staff 6 stated no. The time was approximately 6:58 AM. A [DATE] EMS Report revealed the dispatcher was notified at 6:51 AM EMS arrived at Resident 12 at 6:59 AM. On [DATE] at 11:01 AM Staff 4 stated Staff 6 approached her between 6:30 AM and 6:40 AM and reported Resident 12 was dead. Staff 4 stated to Staff 6 she thought Resident 12 was full code (need to initiate CPR). Staff 4 stated to Staff 6 she needed to do CPR and Staff 4 called EMS. On [DATE] Staff 2 (LPN) stated Staff 6 approached the nurses station and inquired where the crash cart was located. Staff 2 stated Staff 6 explained to her a resident was dead and CPR needed to be initiated. Staff 2 and Staff 54 (LPN) obtained the crash cart and ran down the hall to Resident 12's room. Staff 6 stated they did not need to run as Resident 12 had been dead a while. Staff 2 stated they started CPR on Resident 12 until emergency medical personnel arrived around 7:00 AM. On [DATE] Staff 6 (LPN) stated a CNA approached her about 6:30 AM and stated she thought Resident 12 was dead. Staff 6 assessed Resident 12 and she/he had no vital signs and Staff 6 felt the resident was dead for a while. Staff 6 stated she went to Staff 4 who checked the advance directive book (to determine if CPR was initiated for residents) Staff 4 stated Resident 12 did not have an advance directive so CPR needed to be started. Staff 6 stated she went to the other nurse's station and asked about the crash cart. Staff 2 and Staff 54 ran down the hall toward the room and Staff 6 stated they did not need to run as Resident 12 had been dead a while. A [DATE] Investigation revealed on [DATE] the following occurred: -Staff 8 (CNA) found Resident 12 not breathing at approximately 6:20 AM. Staff 8 ran to Wing 2 nurses' station, informed Staff 6 and she stated I got it from here if I need help I will ask you. -Staff 4 reported on [DATE] between 6:30 AM and 6:40 AM Staff 6 approached her and stated Resident 12 was unresponsive. Staff 4 informed Staff 6 Resident 12 was a full code. Staff 4 and Staff 6 went into the room and after Staff 4 observed Resident 12 she went to call 911 as Staff 6 went to obtain the crash cart. -Staff 9 (CNA) stated Staff 6 did not know where the crash cart was located. -Staff 54 stated he saw an older nurse waking down the hall with a crash cart at a slow pace. Staff 54 asked what happened and after Staff 6 informed him, he ran to the room to initiate CPR. -Staff 1 (Administrator) stated she received a call at 6:46 AM stating Resident 12 was dead. During a second call at 7:00 AM Staff 1 was informed CPR was initiated before the 6:46 call was ended. -Staff 4 stated at approximately 6:50 AM Staff 6 inquired where the crash cart was located and reported CPR was not yet started. Staff 6 reported at approximately 6:30 AM Staff 8 informed her Resident 12 needed to be seen right away. The report revealed licensed nurses were re-educated on [DATE] related to CPR policy, code status and the running of a mock code. A [DATE] Performance Improvement Action Plan revealed the following: -Re-education provided to nurse staff on CPR policy, presumptive and irreversible signs of death and code status. -Validate and verify code status in clinical record of current residents. -Validate licensed nurses CPR certification. -Chart review of residents who expired in last 30 days to verify advance directive followed. -Mock codes implemented monthly. -Code status reviewed weekly for four weeks then monthly thereafter. -CPR certification of licensed nurses reviewed monthly. -Chart review of expired residents completed to verify advance directive weekly for four weeks. -Audit trends presented for review at Quality Assessment and Assurance for further recommendations. On [DATE] at 2:22 PM Staff 37 (Regional Nurse Consultant) confirmed Resident 12 was not administered CPR timely as required and the facility initiated a plan of correction and provided training to the staff due to the concern. On [DATE] at 2:23 PM Staff 37 was informed of the past non-compliance Immediate Jeopardy.

1. Based on interview and record review it was determined the facility failed to provide supervision for a resident at risk for falls for 1 of 3 sampled residents (#2) reviewed for falls. Resident 2 was left on the toilet in the bathroom alone, the resident stood, fell , was hospitalized and was assessed to have a new right side [MEDICAL CONDITION] (brain bleed). Findings include: Resident 2 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 3/9/18 hospital Discharge Summary indicated Resident 2 fell out of bed, was hospitalized and had surgical repair of the left leg. The orders indicated the resident was to not bear weight on the left arm and was to keep the arm in a sling as tolerated. The Nursing Admission/Readmission Evaluation dated 3/9/18 indicated the resident was alert and oriented to person, time and situation. The resident required extensive assistance with one staff to dress, bathe, move in bed and for toileting. The assessment indicated the resident was at risk for falls. The Care Plan initiated on 3/9/18 indicated the resident was at risk for falls. Interventions included the staff were to anticipate the resident's needs, ensure the call light was in place and staff were to promptly respond to the resident's needs. The staff were also to ensure commonly used items were within reach of the resident. Progress Notes revealed the following: -3/10/18 The resident self transferred. The resident was reminded to always ask for assistance when walking. The resident was alert to self but was confused. -3/12/18 Physician Note indicated the resident had moderate dementia. The resident was at the facility for therapy. The therapy department recommended the resident was to bear weight as tolerated for the left hip. The resident was assessed to be alert to self and had difficulty maintaining thought processes. The Unwitnessed fall investigation indicated on 3/15/18 at 4:45 am a loud crash was heard. The resident was found on her/his buttocks on the fall mat. The resident's incontinent brief was not on and the resident was found to be continent. The resident denied pain. The note indicated the resident is unable to remember to use the call light. The bed was in the lowest position and the call light was within reach. The predisposing factors included the resident had impaired memory and weakness. The Care Plan was updated on 3/15/18 to include the bed was to be in the lowest position and fall mats were to be at on the floor at the side of the bed. The 3/15/18 Unwitnessed fall investigation indicated Resident 2 fell on [DATE] at approximately 4:00 pm. The resident was found on the floor on the fall mat to the right side of the bed, the resident's bed was in the lowest position and the resident wore non-skid socks. The resident reported she/he wanted to get up to bring the physician pickles. The note indicated the staff were advised to check on the resident every five to 10 minutes to ensure the resident did not attempt to self transfer. The note also indicated the resident attempted to get out of bed several times through the evening shift and staff were able to guide the resident back to bed or the wheelchair. No injuries were identified post fall. The two 3/15/18 fall investigations indicated the resident did not activate the call light and was found on the ground. The Care Plan was not updated after the two falls with additional interventions to address the resident did not remember to use the call light. The 3/16/18 Unwitnessed fall investigation indicated on 3/16/18 at 12:45 am a CNA assisted the resident to the bathroom for toileting. The CNA left the resident in the bathroom and left the room to obtain a clean gown for the resident. The CNA was gone for approximately one to two minutes. Staff 6 (LPN) entered the resident's room as the CNA re-entered the room. Staff 6 found the resident on the bathroom floor. The resident had an obvious injury and skin tear to the right eyebrow. On 5/21/18 at 12:07 pm Staff 2 (GNA/Graduate Nursing Assistant) indicated she was not assigned to work with Resident 2 on 3/16/18. Staff 22 (CNA) was the resident's assigned CNA but Resident 2 did not want a male staff to assist with toileting. Staff 2 indicated she worked with the resident in the past and was aware the resident had a history of [REDACTED]. Staff 2 indicated if she assisted a resident to the bathroom she usually stayed in the bathroom with the resident or stood outside the door with the door cracked in order to monitor the resident. On 3/16/18 Staff 22 assisted the resident to the wheelchair and then asked Staff 2 to assist the resident with toileting. Staff 2 assisted the resident to transfer from the wheelchair to the toilet. After the resident was transferred to the toilet she noticed the resident's gown was wet. Staff 2 left the room to go to the linen room. She provided the resident the call light and the resident demonstrated she/he was able to use the light. Staff 2 indicated Staff 22 was near the resident bathroom but did not go into the bathroom until the resident fell . Staff 2 indicated approximately one week after the fall staff were educated to not leave a confused resident in the bathroom alone. On 5/24/18 at 11:07 pm Staff 22 indicated he did not work with Resident 2 before 3/16/18 but was aware the resident fell at the facility. On 3/16/18 the resident was agitated and resistive to care. Staff 22 and Staff 6 assisted the resident to the wheelchair. The resident did not appear to want male staff to assist her/him with toileting. Staff 22 requested Staff 2 to assist the resident with toileting. Staff 22 indicated after Staff 2 took the resident to the bathroom he left the area to pass fresh water to the other residents and answer call lights. Staff 22 indicated Resident 2 fell after Staff 2 left the resident in the bathroom to obtain a clean gown. Staff 22 indicated he would not leave residents in the bathroom alone if the resident was confused and had a history of [REDACTED]. On 5/18/18 at 8:43 am Staff 6 (LPN) indicated the resident was weak on one side. The resident was confused, tried multiple times to get out of bed without assistance and had a history of [REDACTED]. Staff 6 indicated he and Staff 22 were at the nurse's station across from the resident's room. Staff 6 indicated Staff 2 could have asked them to get a gown for the resident and not leave the resident alone in the bathroom. On 5/14/18 at 4:30 pm Staff 23 (GNA) indicated if a resident was at risk for falls and had a history of [REDACTED]. If the resident required a new gown she would pull the bathroom call light and ask staff to bring her a gown. On 5/14/18 at 4:35 pm Staff 24 (CNA) indicated if a resident had a history of [REDACTED]. Staff 14 indicated she would use the call light to summon staff or she would assist the resident back to bed and then obtain a clean gown. On 5/15/18 at 2:15 Staff 25 (LPN Unit Manager) indicated if a resident had a history of [REDACTED]. Staff could give as much privacy as possible but continue to keep an eye on the resident. Staff 25 indicated the linen room was quite a distance from Resident 2's room. On 5/17/18 at 11:07 am Staff 7 (LPN) indicated if a resident had a history of [REDACTED]. Staff could provide privacy but keep the resident in their peripheral line of sight. On 5/17/18 at 11:30 am Staff 5 (CNA) indicated if a resident was confused, did not use the call light and had a history of [REDACTED]. Staff 5 indicated she would attempt to provide the resident privacy by turning her body but continue to keep the resident in line of sight or she would keep her hand on the resident's shoulder. On 5/15/18 at 1:15 pm Staff 4 (DNS) indicated Resident 2's room was near the nurses station. On 3/16/18 the incident report indicated the resident attempted to get out of bed and staff were to monitor the resident. Staff 4 indicated Staff 2 was a GNA and did not have a lot of experience. Staff 2 was provided education to not leave the resident in the bathroom if the resident had a history of [REDACTED]. The 3/16/18 Nursing Neurological Observation indicated at 5:30 am Resident 2 was confused and 6:30 am the resident was identified to be lethargic. On 5/17/18 at 11:22 pm Staff 8 (LPN Unit Manager) indicated on 3/16/18 the day nurse requested she assess the resident's eyebrow laceration. The laceration was by the right temple. After the resident was assessed it was determined the resident was to be transported to the hospital for evaluation. Staff 8 also indicated as time progressed the resident was more lethargic. The hospital 3/16/18 at 9:50 am and 12:05 pm Emergency Department Triage Notes indicated the resident fell in the bathroom on 3/16/18 around midnight and hit her/his head. The hospital 3/16/18 Consult Note indicated the resident's speech was thick and slightly slurred. The resident had a head scan and there was a frontal hemorrhagic contusion (bleeding to the frontal region of the brain). The resident was admitted for close neurological monitoring. 2. Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed and had care plans developed to safely smoke for 3 of 4 sampled residents (#s 1, 6 and 7) identified to smoke. Findings include: The facility 9/2016 Resident Smoking Policy and Procedure included: -The facility believed smoking and vaping (the inhalation/exhalation of the vapor produced by an electronic cigarette) presented a serious risk to a person's health and safety. -The facility provided an environment which allowed residents the opportunity to vape or smoke in a safe environment -a smoking assessment would be conducted by a licensed nurse for residents upon admission who wished to smoke and residents were reassessed PRN. -The smoking assessment would determine if the resident was independent or required supervision a. Resident 1 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 3/1/18 Smoking Screen indicated Resident 1 did not smoke. The 3/8/18 Admission MDS indicated the resident smoked. The resident's record did not have additional information to indicate if the resident was assessed to smoke, if the resident continued to smoke and if the resident was independent to smoke or required staff supervision. The Care Plan initiated on 3/1/18 did not have documentation to indicate if the resident smoked and the amount of supervision required if the resident smoked. On 5/18/18 Staff 14 (CNA) indicated Resident 1 smoked but not very often. The resident was assisted to smoke in the designated smoking area by staff or family. On 5/14/18 Staff 8 (LPN Unit Manager) indicated Resident 1 did not smoke and verified the smoking assessment indicated Resident 1 did not smoke. On 5/14/18 at 3:35 pm Staff 12 (RNCM) indicated Resident 1 smoked and at times the family assisted the resident outside to smoke. Staff 12 acknowledged the resident's record did not have a smoking assessment and there was no care plan related to smoking. On 5/14/18 at 4:00 pm Staff 13 (MDS Coordinator) indicated the resident smoked and staff assisted the resident. The resident was not safe to smoke without supervision and was not able to propel her/himself in a wheelchair. On 5/15/18 at 3:10 pm Staff 4 (DNS) acknowledged Resident 1 was not assessed to smoke and a care plan was not developed related to smoking. b. Resident 6 was admitted to the facility in (YEAR) with spinal stenosis (narrowing of the spinal canal). The 4/12/18 Nursing Admission/Readmission Evaluation indicated the resident smoked two to five cigarettes daily. The resident did not have cognitive issues, did not have dexterity problems and was able to light a cigarette independently. The assessment did not indicate if the resident was able to use the fire extinguisher and if the resident was independent to smoke or required supervision. The current Visual/Bedside Kardex Report (resident specific care interventions) and the Care Plan initiated on 4/11/18 did not identify the resident to smoke and did not indicate if staff were to supervise the resident when the resident smoked. On 5/15/18 at 11:05 am Staff 17 (LPN) indicated the resident independently vaped and was safe. On 5/15/18 at 4:30 pm Staff 4 (DNS) indicated residents were to be assessed and a care plan was to be developed if the resident was identified to smoke. Staff 4 acknowledged there was no assessment to indicate the resident was safe to smoke independently. c. Resident 7 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. The 5/9/18 Smoking Screen indicated the resident did not smoke. The 5/9/18 Nursing Admission/Readmission Evaluation indicated the resident smoked. The chart did not have documentation to indicate the resident had an assessment to determine if the resident was safe to smoke independently or required supervision and there was no care plan related to the resident's smoking status. On 5/15/18 at 5:05 pm Resident 7 was observed in the facility designated smoking area. The resident indicated she/he just finished smoking a cigarette. The resident indicated she/he usually vaped but a part of the vaporizer was broke and family was to bring in another part. The resident was observed to have good fine motor skills and the resident was able to verbalize where the fire extinguisher was located and verbalized she/he knew how to use the extinguisher. On 5/15/18 at 10:10 am Staff 18 (Assistant Administrator) indicated upon resident admission to the facility a smoking evaluation was to be completed. The electronic cigarettes were included in the smoking evaluation and the smoking policy was to be followed. Staff 18 indicated she would look for a smoking assessment and care plan for Resident 7. The Smoking Screen completed on 5/15/18 at 5:10 pm indicated the resident was assessed to be able to smoke without supervision.

Based on observation, interview and record review it was determined the facility failed to prevent the development of pressure ulcers related to the use of medical devices for 2 of 5 residents (#s 15, 115) reviewed for pressure ulcers. Resident 15 developed a Stage 3 pressure ulcer (Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling.) This placed residents at increased risk for complications associated with impaired skin integrity such infection and pain. Findings include: A medical device-related pressure ulcer (MDRPU) is defined as a localized injury to the skin or underlying tissue resulting from sustained pressure caused by a medical device, such as a brace; splint; cast; respiratory mask or tubing. Many pressure ulcers result not from the device itself but from poor device positioning, securement or simple failure to check under the the device. Preventive practices include frequently evaluating device positioning and securement and loosen the device at least once per shift to check for skin problems. (Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMSEditor-in-Chief Wound Care Advisor). 1. Resident 15 was readmitted to the facility in 2013 with [DIAGNOSES REDACTED]. Resident 15's 8/29/14 quarterly MDS indicated the resident was totally dependent for all ADLs and "continued to display verbal abuse and refusal of care." Resident 15 had a contracture at the left elbow and had no skin issues. Resident 15's Comprehensive Care Plan updated 8/28/14 identified skin breakdown risks related to being incontinent and having impaired mobility due to left [MEDICAL CONDITION]. In addition to other pressure ulcer prevention interventions staff were to place a pillow, stuffed animal or cushion under the resident's left arm when she/he was in a wheelchair. An Incident Report dated 9/13/14 indicated Resident 15 developed an open wound to her/his left (contracted) inner elbow. The resident "had been wearing a protective sleeve to prevent bruising to arm." The injury was assessed as a skin erosion (a loss of some or all of the outer layer of skin) and treated. The investigation dated 9/17/14 determined the erosion was caused by a geri sleeve "wrinkled-up" on the antecubital (inside elbow) site. It was noted Resident 15 was at risk for skin breakdown and staff usage of geri sleeves would be reviewed. The facility Skin Care Progress sheet dated 9/13/14 described the wound as 2 cm x 1.5 cm and 1.2 cm deep. The causative factor was a geri sleeve in place on contracted elbow. The wound was not re-assessed as a pressure ulcer and was not staged. A physician progress notes [REDACTED]. changed/removed and caused a stage III pressure ulcer." The physician ordered no more compression sleeve and to "monitor staff closely for appropriate care." Resident 15's TAR (part of the care plan) did not include information regarding use of a geri or compression sleeve. It was not know when and who initiated the geri sleeve, how long it was to be worn daily and who would monitor the use. On 10/20/14 at 11:11 am Staff 2 (RNCM) indicated Resident 15 had a contracture at the left elbow and had no pressure ulcers. On 10/22/14 11:22 am Staff 4 (LPN) stated she thought the resident's wound was due to a geri sleeve being worn too tight. She said Staff 2 (RNCM) would have assessed and staged the wound if it was a pressure ulcer. On 10/22/14 at 2:16 pm and 2:23 pm Staff 5 and 6 (day and evening shift CNAs) stated the geri sleeve was to protect Resident 26 from skin tears. Staff 5 stated sometimes the geri sleeve was off when she came in the morning and she would put it on. She stated the sleeve fit snuggly and was made of elastic. Staff 6 said he left the sleeve on the resident all night. On 10/22/14 at 2:59 pm Staff 2 (RNCM) stated normally pressure ulcers were on a bony prominence and this was in the soft inner elbow so she chose to not call it a pressure ulcer but erosion of the skin. Staff 2 stated when she saw" white tendon" she realized it was a full thickness wound. (National Pressure Ulcer Advisory Panel: full thickness skin loss with damage to muscle, bone or supporting structure (tendon) was associated with a Stage IV pressure ulcer). Staff 2 did not re-assess or stage the wound as a pressure ulcer. Staff 2 stated she did not believe a CNA would initiate the use of geri sleeves. Staff 2 stated the monitoring for the geri sleeve should be on the TAR and she expected a nurse to check the placement and skin every shift. She stated the geri sleeve may not be on the In Room Care Plan (IRCP) for CNAs, but it should be on the Comprehensive Care Plan. Staff 2 stated when a medical device was initiated by nurses they would document the monitoring each shift on the TAR. Staff 2 was unaware the use of the geri sleeve was not on the resident's care plan or TAR. On 10/2314 at 7:47 am Staff 1(DNS) and Staff 14 (Corporate Nurse Consultant) stated there was a standard of practice regarding monitoring medical devices and confirmed when a device was initiated a nurse would care plan and document the use on the TAR. 2. Resident 115 was admitted to facility in September 2014 with [DIAGNOSES REDACTED]. The Pressure Ulcer CAA from the MDS dated [DATE] identified multiple risk factors and determined the resident was at high risk for pressure ulcers. The Comprehensive Care Plan dated 9/22/14 was updated on 10/11/14 and 10/22/14. The residen'ts heels were to be "floated" off the mattress with the use of a cushion and the resident was provided with an air bed and schedule for repositioning. Review of the October, 2014 Progress Notes revealed the resident was hospitalized briefly to repair a dislocation of the right hip prosthesis. Resident 115 was re-admitted on [DATE] with an immobilizer on the right knee to be worn under the resident's clothing, against her/his skin. The use of the immobilizer was not added to the Comprehensive Care Plan. A physician's orders [REDACTED]. The In Room Care Plan (IRCP) was updated on 10/16/14 to include this information. There was no other information on the IRCP related to periodically removing the immobilizer and inspecting the skin underneath. Nursing Notes from 10/22/14 described a new stage 2 pressure ulcer on the resident's posterior lower leg (Stage 2 - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister.) The dark red intact skin surrounding the open area was described with "features of deep tissue injury" presenting as darker, bruised appearing skin. On 10/23/14 at 3:30 pm Staff 17 (RN) stated she found the pressure ulcer on Resident 115's right calf when assessing the resident for a new open area on the right heel on 10/22/14 . She removed the knee immobilizer from the resident's right leg and found the area on the posterior lower leg under the brace. The brace was not routinely removed when the resident was in bed. On 10/24/14 at 9:10 am Resident 115 gave permission for an RN surveyor to observe wound care to her/his right leg. On 10/24/14 at 9:26 am a reinforced fabric knee immobilizer was observed on the resident's right leg extending above and below the knee. The device was secured with wide Velcro closures and had a ridged "spine" that extended the length of the brace. The rigid component was covered with thin blue foam as an extra layer of padding. After staff opened and removed the immobilizer, dark red stains could be seen on the interior surface of the brace where it contacted the resident's calf to the right and just below the ridged spine. The wound on the resident's right calf was observed to be consistent with the description in the nurses' notes, a small shallow open area with red to dark red intact skin surrounding the open area. A small area adjacent to the top of the wound had a very slight purple color. The wound bed was without slough. Resident 115 denied pain from the wound when asked by the nurse. On 10/24/14 at 11:54 am Staff 10 (RNCM) stated he considered it standard practice for nursing staff to remove removeable immobilizers or splints to inspect skin underneath. Staff 10 confirmed the intervention to remove the device twice a day and inspect skin for breakdown was added on 10/23/14 after the right calf wound was found.

Based on interview and record review it was determined facility staff failed to meet professional standards of care regarding safety when transporting a resident in a wheelchair for 1 of 3 sampled residents (#3) reviewed for accidents. This resulted in the resident's leg hitting the floor during wheelchair transport, increased and uncontrolled pain, the resident was sent to the hospital and was diagnosed with [REDACTED]. Review of Oregon State Board of Nursing Standards and Authorized Duties for Certified Nursing Assistants [PHONE NUMBER] Standards of Care for CNAs (6)(j) indicated the CNA shall consistently apply safety concepts in the workplace; Conduct Unbecoming a Nursing Assistant [PHONE NUMBER](1) included conduct related to client safety which may adversely affect health and safety. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A NN dated 6/13/14 at 2:26 am indicated Resident 3 had no complaints of pain. An Occupational Therapy note dated 6/13/14 at 1:48 pm indicated Resident 3 was in significant pain because the resident's affected leg hit the floor hard while the resident was being transported in a wheelchair without footrests. A Physical Therapy note dated 6/13/14 at 3:52 pm indicated Resident 3 was unable to ambulate due to pain. A NN dated 6/13/14 at 4:29 pm indicated Resident 3 reported increased pain after the resident's leg dropped during wheelchair mobility. Complaints of pain in the right hip were not controlled with pain medication. The resident was sent to the hospital for evaluation. A Resident Incident Report dated 6/13/14 indicated Staff 5 (CNA) was transporting Resident 3 in a wheelchair from the resident's room to be weighed on a scale. Staff 5 did not use footrests on the wheelchair but asked the resident to hold her/his legs up. While being transported the resident's right operative leg dropped to the floor. The resident complained of increased right leg pain. A written statement by Staff 5 dated 6/13/14 indicated she was transporting Resident 3 in a wheelchair without footrests from the resident's room to a scale to be weighed. Staff 5 indicated she did not put footrests on the wheelchair because she earlier weighed the empty wheelchair without them. Instead of putting the footrests on she told the resident to hold her/his legs up. A few feet outside the resident's room, the resident dropped her/his feet to the ground while the wheelchair was in motion and cried out in pain. The resident was assisted back to bed and was in more pain than before. The resident was crying in pain and the pain pills did not help. The resident was sent to the hospital. A hospital History and Physical dated 6/13/14 revealed Resident 3 was readmitted to the hospital for pain management related to a new pubic rami (part of the pelvis) fracture. X-ray results indicated the right inferior pubic ramus fracture appeared new. A review of Resident 3's clinical record revealed the In Room Care Plan dated 6/12/14 was blank and the Initial Care Plan dated 6/12/14 was blank. In interviews on 7/29/14 at 11:53 am and 2:47 pm, and on 8/1/14 at 9:41 am Staff 5 stated she was going to weigh Resident 3 and was transporting the resident in a wheelchair without leg rests. The resident's legs dropped to the floor during transport and the wheelchair continued forward slightly before she stopped the wheelchair. Staff 5 stated an hour later the resident was crying in pain. Pain pills did not help relieve the resident's pain. Staff 5 stated she did not check the In Room Care Plan prior to providing care to the resident. Staff 5 was told in shift report the resident had hip surgery. Staff 5 stated CNAs are supposed to check the In Room Care Plan when providing care for a new resident. Staff 5 stated she may have taken Resident 3's footrests off the wheelchair prior to wheeling the resident to be weighed, because earlier she had weighed the empty wheelchair without the footrests on. Staff 5 stated she probably took them off. On 7/31/14 at 2:12 pm Witness 5 (Family) stated when she/he came to visit Resident 3 on the morning of 6/13/14 the resident was in a wheelchair eating breakfast in the resident's room. Staff 5 entered the room and told the resident she wanted to weigh her/him. Witness 5 stated Staff 5 removed the footrests from the wheelchair, wheeled the resident out of the room, and right after she turned the corner leaving the room, the resident's right leg went down to the floor and jammed the resident's leg from ankle to hip. The resident was in extreme pain. Staff 5 continued to take the resident to the scale to be weighed. The resident was doubled over in pain. Witness 5 stated she/he reported what happened to the nurse. The resident's pain was much worse after the incident, it was extreme. The pain did not subside after pain medication was given to the resident. The nurse called the physician and was instructed to send the resident to the emergency room . Witness 5 stated the hospital did x-rays and compared them to the resident's prior x-rays and determined the resident had a new pelvic fracture. The resident spent seven hours in the emergency room and was admitted to the hospital for four days to get her/his pain under control. On 7/31/14 at 3:00 pm Witness 4 (Physical Therapist) stated she did an evaluation on Resident 3 the morning of 6/13/14. She had a CNA assist her with transferring the resident to the bathroom. The CNA asked her if she needed to put the footrests on the wheelchair before she weighed the empty wheelchair. Witness 4 told the CNA she did not need to put the footrests on to weigh the empty wheelchair. Witness 4 stated she offered to weigh the resident for the CNA. Witness 4 stated she wheeled the resident onto the scale with the footrests on, removed the footrests, weighed the resident, put the footrests back on, wheeled the resident back to the resident's room, and wrote the weight on the white board in the resident's room because she could not find the CNA. Witness 4 stated footrests should have been used when transporting the resident in a wheelchair and the resident probably would not have been able to hold her/his legs up for very long while in the wheelchair. On 8/1/14 at 11:06 am Resident 3 stated a lady came into her/his room and put her/him in a wheelchair and left the room. She came back in the room took the footrests off the wheelchair and told the resident she was going to take the resident to be weighed. The resident told the staff someone already weighed her/him. The staff stated she didn't care and was going to weigh the resident anyway. The staff wheeled the resident 1-2 steps out of the door and the resident's foot hit the floor. The resident screamed it hurt so bad. The staff waited a second then wheeled the resident to the scale to be weighed. Resident 3 restated the wheelchair had the footrests on but the staff member took them off the wheelchair before wheeling the resident out of the room. The resident stated the pain was excruciating. On 7/29/14 at 1:26 pm Staff 2 (RNCM) stated after the incident she counseled Staff 5 it was most appropriate to transport residents with a recent hip surgery using a wheelchair with footrests. Staff 2 stated it was a standard of practice. Staff 2 stated CNAs use the In Room Care Plan (IRCP) to know how to care for a resident. The IRCP was supposed to be completed by the admitting nurse within a few hours of a resident being admitted to the facility. Staff 2 stated she did not know why Resident 3's IRCP was not completed. Staff 2 stated Staff 5 should have consulted with a nurse prior to transporting Resident 3. On 7/29/14 in the afternoon, Witness 3 (Physical Therapist) stated the proper way to transport a resident who was one week post hip replacement surgery in a wheelchair depends on the resident's precautions but footrests of an appropriate length should be used. On 7/29/14 at 1:43 pm and on 7/30/14 at 10:36 am Staff 4 (DNS) stated it was the facility's practice for CNAs to check the IRCP to determine if footrests were supposed to be used when a resident was transported in a wheelchair. Staff 4 stated Staff 5 was following Resident 3's IRCP at the time of the incident. Staff 4 stated she was not aware Resident 3's IRCP was blank. Staff 4 stated if the IRCP was blank Staff 5 should not have transported the resident and checked with a nurse. Staff 4 acknowledged Resident 3's In Room Care Plan was blank. On 8/6/14 at 2:11 pm, Witness 14 (Surgeon) stated Resident 3 had very soft bones and the incident at the facility could have caused the resident's pubic rami fracture. Witness 14 stated he did not appreciate another fracture. Refer to F-323

Based on interview and record review it was determined the facility failed to safely transport a resident in a wheelchair for 1 of 3 sampled residents (#3) reviewed for accidents. This resulted in the resident's leg hitting the floor during wheelchair transport, increased and uncontrolled pain, the resident was sent to the hospital and was diagnosed with [REDACTED]. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A NN dated 6/13/14 at 2:26 am indicated Resident 3 had no complaints of pain. An Occupational Therapy note dated 6/13/14 at 1:48 pm indicated Resident 3 was in significant pain because the resident's affected leg hit the floor hard while the resident was being transported in a wheelchair without footrests. A Physical Therapy note dated 6/13/14 at 3:52 pm indicated Resident 3 was unable to ambulate due to pain. A NN dated 6/13/14 at 4:29 pm indicated Resident 3 reported increased pain after the resident's leg dropped during wheelchair mobility. Complaints of pain in the right hip were not controlled with pain medication. The resident was sent to the hospital for evaluation. A Resident Incident Report dated 6/13/14 indicated Staff 5 (CNA) was transporting Resident 3 in a wheelchair from the resident's room to be weighed on a scale. Staff 5 did not use footrests on the wheelchair but asked the resident to hold her/his legs up. While being transported the resident's right operative leg dropped to the floor. The resident complained of increased right leg pain. An attached NN dated 6/13/14 by Staff 2 (RNCM) and indicated Resident 3's pre-admission hip fracture was "spontaneous" in nature, the resident fell three weeks before the hip fracture and broke her/his wrist, and no prior x-ray reports indicated the new pelvic fracture area was previously evaluated. A review of Resident 3's clinical record revealed no indication the resident's hip fracture was spontaneous, no indication the resident broke her/his wrist, and did indicate pelvic x-rays were done on 6/5/14. A written statement by Staff 5 dated 6/13/14 indicated she was transporting Resident 3 in a wheelchair without footrests from the resident's room to a scale to be weighed. Staff 5 indicated she did not put footrests on the wheelchair because she earlier weighed the empty wheelchair without them. Instead of putting the footrests on she told the resident to hold her/his legs up. A few feet outside the resident's room, the resident dropped her/his feet to the ground while the wheelchair was in motion and cried out in pain. The resident was assisted back to bed and was in more pain than before. The resident was crying in pain and the pain pills did not help. The resident was sent to the hospital. A hospital History and Physical dated 6/13/14 revealed Resident 3 was readmitted to the hospital for pain management related to a new pubic rami (part of the pelvis) fracture. X-ray results indicated the right inferior pubic ramus fracture appeared new. A review of Resident 3's clinical record revealed the In Room Care Plan dated 6/12/14 was blank and the Initial Care Plan dated 6/12/14 was blank. In interviews on 7/29/14 at 11:53 am and 2:47 pm, and on 8/1/14 at 9:41 am Staff 5 stated she was going to weigh Resident 3 and was transporting the resident in a wheelchair without leg rests. The resident's legs dropped to the floor during transport and the wheelchair continued forward slightly before she stopped the wheelchair. Staff 5 stated an hour later the resident was crying in pain. Pain pills did not help relieve the resident's pain. Staff 5 stated she did not check the In Room Care Plan prior to providing care to the resident. Staff 5 was told in shift report the resident had hip surgery. Staff 5 stated CNAs are supposed to check the In Room Care Plan when providing care for a new resident. Staff 5 stated she may have taken Resident 3's footrests off the wheelchair prior to wheeling the resident to be weighed, because earlier she had weighed the empty wheelchair without the footrests on. Staff 5 stated she probably took them off. On 7/31/14 at 2:12 pm Witness 5 (Family) stated when she/he came to visit Resident 3 on the morning of 6/13/14 the resident was in a wheelchair eating breakfast in the resident's room. Staff 5 entered the room and told the resident she wanted to weigh her/him. Witness 5 stated Staff 5 removed the footrests from the wheelchair, wheeled the resident out of the room, and right after she turned the corner leaving the room, the resident's right leg went down to the floor and jammed the resident's leg from ankle to hip. The resident was in extreme pain. Staff 5 continued to take the resident to the scale to be weighed. The resident was doubled over in pain. Witness 5 stated she/he reported what happened to the nurse. The resident's pain was much worse after the incident, it was extreme. The pain did not subside after pain medication was given to the resident. The nurse called the physician and was instructed to send the resident to the emergency room . Witness 5 stated the hospital did x-rays and compared them to the resident's prior x-rays and determined the resident had a new pelvic fracture. The resident spent seven hours in the emergency room and was admitted to the hospital for four days to get her/his pain under control. Witness 5 stated on two occasions when she/he returned to the facility to retrieve the resident's belongings, she/he asked the charge nurse about the facility's reporting responsibilities and was told on both occasions the nurses did not know about reporting and it was an administrative function. Witness 5 stated on 6/16/14 she/he spoke with Staff 12 (Administrator) and the Staff 4 (DNS) and asked them about the facility's reporting responsibilities, and was told the facility had done nothing wrong and it was not abuse or neglect. On 7/31/14 at 3:00 pm Witness 4 (Physical Therapist) stated she did an evaluation on Resident 3 the morning of 6/13/14. She had a CNA assist her with transferring the resident to the bathroom. The CNA asked her if she needed to put the footrests on the wheelchair before she weighed the empty wheelchair. Witness 4 told the CNA she did not need to put the footrests on to weigh the empty wheelchair. Witness 4 stated she offered to weigh the resident for the CNA. Witness 4 stated she wheeled the resident onto the scale with the footrests on, removed the footrests, weighed the resident, put the footrests back on, wheeled the resident back to the resident's room, and wrote the weight on the white board in the resident's room because she could not find the CNA. Witness 4 stated footrests should have been used when transporting the resident in a wheelchair and the resident probably would not have been able to hold her/his legs up for very long while in the wheelchair. On 8/1/14 at 11:06 am Resident 3 stated a lady came in the resident's room and put her/him in a wheelchair and left the room. She came back in the room took the footrests off the wheelchair and told the resident she was going to take the resident to be weighed. The resident told the staff someone already weighed her/him. The staff stated she didn't care and was going to weigh the resident anyway. The staff wheeled the resident 1-2 steps out of the door and the resident's foot hit the floor. The resident screamed it hurt so bad. The staff waited a second then wheeled the resident to the scale to be weighed. Resident 3 restated the wheelchair had the footrests on but the staff member took them off the wheelchair before wheeling the resident out of the room. The resident stated the pain was excruciating. On 7/29/14 at 1:26 pm and on 8/1/14 at 2:20 pm Staff 2 (RNCM) stated after the incident she counseled Staff 5 it was most appropriate to transport residents with a recent hip surgery using a wheelchair with footrests. Staff 2 stated it was a standard of practice. Staff 2 stated CNAs use the In Room Care Plan (IRCP) to know how to care for a resident. The IRCP was to be completed by the admitting nurse within a few hours of a resident being admitted to the facility. Staff 2 stated she did not know why Resident 3's IRCP was not completed. Staff 2 stated Staff 5 should have consulted with a nurse prior to transporting Resident 3. Staff 2 acknowledged Resident 3's clinical record did not state the resident's hip fracture was spontaneous, did not state the resident had a wrist fracture, and the record did indicate pelvic x-rays were done on 6/5/14. Staff 2 stated it was her clinical inference the resident's hip fracture was spontaneous. On 7/29/14 in the afternoon, Witness 3 (Physical Therapist) stated the proper way to transport a resident who was one week post hip replacement surgery in a wheelchair depends on the resident's precautions but footrests of an appropriate length should be used. On 7/29/14 at 1:43 pm and on 7/30/14 at 10:36 am Staff 4 (DNS) stated it was the facility's practice for CNAs to check the IRCP to determine if footrests were supposed to be used when a resident was transported in a wheelchair. Staff 4 stated Staff 5 was following Resident 3's IRCP at the time of the incident. Staff 4 stated she was not aware Resident 3's IRCP was blank. Staff 4 stated if the IRCP was blank Staff 5 should not have transported the resident and checked with a nurse. Staff 4 acknowledged Resident 3's In Room Care Plan was blank. On 8/6/14 at 2:11 pm, Witness 14 (Surgeon) stated Resident 3 had very soft bones and the incident at the facility could have caused the resident's pubic rami fracture. Witness 14 stated he did not appreciate another fracture.

Based on interviews and record review it was determined the facility failed to administer medications for 1 of 5 sampled residents (#1) without a significant medication error. Resident 1 was given Resident 3's [MEDICATION NAME] (anti-anxiety medication) as a result Resident 1 fell and sustained a right femur fracture requiring surgical repair. Findings include: Resident 1 was admitted to the facility in April 2013 with [DIAGNOSES REDACTED]. The 5/2/13 Departmental Notes written at 7:17 am by Staff 8 (RN) indicated a medication error was discovered during the narcotic count at 6:50 am. The note indicated, on 5/2/13 at 2:30 am, Resident 1 was given two 1 mg tablets of [MEDICATION NAME] instead of two 2 mg tablets of [MEDICATION NAME] (narcotic pain medication) by Staff 8 (RN). Staff 8 indicated at 7:17 am the resident's vital signs were assessed to be within normal limits and the resident was informed of the medication error. Staff 8 stated the resident was given information about [MEDICATION NAME] and the resident stated "I'm okay and feel okay" Staff 8 reported the medication error to the next shift to monitor and the resident's physician was notified of the medication error. The Nursing 2011 Drug Handbook indicates the usual dose of [MEDICATION NAME] for the elderly is 1 to 2 mg orally daily in divided doses. Some of the adverse reactions for the medication is drowsiness, sedation, amnesia, [MEDICAL CONDITION], agitation, dizziness, weakness, unsteadiness, disorientation, depression and headache. The medication is to be used cautiously in the elderly, acutely ill or debilitated. Signs and symptoms of an overdose are drowsiness, confusion, lethargy, ataxia (poor coordination), [DIAGNOSES REDACTED] (decreased muscle tone), [MEDICAL CONDITION] (low blood pressure), hypnotic state, stage 1 to 3 coma and death. The onset for the medication is one hour with the peak of the medication being at two hours. The duration of the medication is 12-24 hours. Staff 8 (RN) completed a Medication Error Report on 5/2/13 to indicate the resident was given the wrong medication and the resident did not experience harm. Staff 8 documented the factors contributing to the error were identified as the "pills look alike, busy ...shift/work hurriedly done ...." The 5/2/13 Departmental Notes written by Staff 9 (RN) at 3:45 pm indicated at the beginning of the day shift the resident was noted to be lethargic, sleepy but arousable. Staff 9 assessed the resident and asked Resident 1 if she/he had ever taken [MEDICATION NAME] before. The resident stated "no, why?" Staff 9 (RN) informed the resident she/he had been given [MEDICATION NAME] instead of [MEDICATION NAME] and asked the resident if she/he remembered being told. The resident stated "no" she could not remember. Staff 9 (RN) indicated Resident 1 kept falling asleep when Staff 9 (RN) was talking with the resident. The notes indicated Resident 1 stated she/he was having trouble waking up and the resident was informed it was an effect of the [MEDICATION NAME]. The resident stated "Oh, I thought she was joking about that." Resident 1 was noted to be lethargic though oriented and received a shower after breakfast. The resident was then assisted into bed and was sleeping at 10:00 am. Staff 9 documented she checked on the resident every 30 minutes and noted the resident was difficult to rouse, had periods of shallow breathing between 10:00 am and 11:30 am and the resident's vital signs were stable. At 11:50 am, Resident 1 was sitting up in bed talking with Staff 12 (Physical Therapy Aide) and Staff 9. Staff 9 documented the resident was able to answer questions appropriately. Staff 9 and 12 left the room and Staff 13 (CMA) went to the resident's rooms with medications. At 11:55 am, Staff 9 was at the medication cart, talking with Staff 13 when Staff 9 heard an exclamation coming from Resident 1's room. The resident was found sitting on the floor next to her/his bed and was visibly upset. Staff 9 stated there was liquid noted on the floor around the resident on her/his legs and soaking her/his pants. Resident 1 stated "no one will tell me what's going on. I was going to the bathroom and I was peeing but there's water all over the floor." The resident denied pain initially though after 5 minutes the resident started to complain of severe left leg pain. The resident was transported to the local hospital emergency department on 5/2/13. The x-rays revealed the resident had a fractured right femur. The resident required surgery to repair the fracture. On 5/6/13, Staff 10 (RNCM) documented the investigation in the Departmental Notes. Staff 10 documented on 5/2/13 at 2:30 am Resident 1 requested a PRN pain medication. Staff 8 (RN) signed out the resident's [MEDICATION NAME] on Resident 1's MAR and signed out the medication on the correct page of narcotic book. Staff 8 (RN) then pulled the medication from the wrong medication card (Resident 3's [MEDICATION NAME]). The resident was to receive [MEDICATION NAME] 2 tablets of 2 mg and Staff 8 administered 2 tablets of 1 mg [MEDICATION NAME]. Staff 10 indicated Resident 3's medication card with [MEDICATION NAME] was two cards behind Resident 1's [MEDICATION NAME]. Staff 10 documented the two drugs ([MEDICATION NAME] and [MEDICATION NAME]) were the same color, both were round though [MEDICATION NAME] was approximately half the diameter of the [MEDICATION NAME]. Staff 8 placed the two tablets of [MEDICATION NAME] in a medication cup and provided them to the resident. Resident 1 did not question the appearance of the medications. The medication error was discovered at 6:50 am when there was an inaccurate count of the narcotic medications. Staff 8 (RN) discovered what had happened and notified the resident of being given the wrong medication. The documentation indicated Staff 8 (RN) explained what [MEDICATION NAME] was and what the medication was used for. Resident 1 stated she/he was "okay" and her/his vital signs were within normal limits. The resident's physician was informed of the medication error and the resident asked the staff not to inform the resident's family. After shift report Staff 9 (RN) assessed the resident. Staff 9 found the resident lethargic, sleepy but arousable. Vital signs were within normal limits. At 7:30 Staff 9 checked the resident's blood sugar and the resident slept intermittently throughout the procedure. At 8:15 am the resident was helped to a sitting position at the side of the bed for breakfast. The CNA report indicated the resident was able to eat 76-100 percent of her/his meal independently. At 9:30 am, the resident received a shower. Staff 14 (CNA) assisted the resident with the transfer to wheelchair then pushed wheelchair to shower room. During the shower the resident remained awake but required more assistance than usual. The resident was unable to hold the shower head and could not wash her/his body. Staff 14 reported the resident was slurring her/his words while in the shower. Resident 1 was assisted with dressing while in the shower room. The resident then requested to go outside for a cigarette. The resident was able to light her own cigarette using an electronic lighter and smoke safely. Staff 14 (CNA) stayed with the resident during this time for safety. The resident was usually an independent smoker. After the cigarette, the resident was assisted back to her/his room and assisted into bed. Staff 14 (CNA) left the room with the resident in bed, bed in lowest position, call light attached to right bed cane and her/his bedside table was along the left side of the bed. Staff 9 (RN) checked on the resident every 30 minutes. Vital signs were within normal limits. At 11:50 am, Staff 9 (RN) walked into the room and resident was sitting at the side of the bed conversing with Staff 12 (PTA). Staff 9 (RN) asked the resident some questions and the resident answered appropriately. Staff 12 stated the resident was too lethargic to participate in therapy. Staff 9 (RN) assisted the resident back to a lying position, covered with blankets, call light still attached to right bed cane, bed in lowest position and bedside table along left side of bed. Staff 9 walked out of the room and went to medication cart approximately 30 feet away from Resident 1's room. Staff 9 reported she was there for about a minute then heard a scream. Resident 1 was found sitting on her/his bottom, legs straight out in front of her/him and back facing the bed. The resident was approximately one foot from the bed and the resident reported "I was going to the bathroom, I was peeing but there was water all over the floor." Staff 6 (DNS) provided the 5/9/13 Employee Corrective Discipline Form signed by Staff 8 (RN). The form indicated Staff 8 failed to follow nursing standards of practice, failed to administer medications in a manner consistent with state and federal law, and did not follow the six rights of medication administration, (right resident, right medication, right dose, right route, right time and right documentation). The form indicated the failure to administer the correct medications contributed to the resident's fall with fracture. Staff 8 was terminated from employment on 5/9/13. An interview on 6/10/13 at 1:30 pm with Staff 13 (CMA) and Staff 14 (CMA) at 1:45 pm revealed Staff 13 and 14 assisted Staff 8 (RN) with the narcotic count on 5/2/13 beginning at 6:30 am. Staff 13 and 14 stated it was discovered there was an error when counting the narcotics. Staff 13 and 14 stated there were too many medications on one card and not enough on the other. Staff 13 and 14 stated the facility's system was the narcotics have a number written on the card and a number written in the narcotic book where the staff documented when the medications were taken from the card. Staff 13 and 14 stated the staff was to find the page for the resident's medication, check the medication against the MAR to make sure it was the right person and right medication. The staff was to sign out the medication in the narcotic books and on the MAR. Staff 13 and 14 stated the narcotic book stated the resident was provided with [MEDICATION NAME] though there was no medication taken from the card of the [MEDICATION NAME]. There were two tablets taken from Resident 3's [MEDICATION NAME] card. Staff 13 and 14 stated Staff 8 (RN) realized what occurred and Staff 8 assessed the resident and determined the resident was fine. Staff 13 stated the resident's vital signs and assessments were done when she went into the room to provide the resident the morning medications. Resident 1 stated she asked how the resident was feeling and her/his response was "fine." Staff 13 stated Resident 1 fell asleep after the breakfast meal was over. Staff 13 and 14 stated the staff needed to make sure the right resident was getting the right medication. Staff 13 and 14 stated the narcotic medications were counted at the change of every shift to ensure the right medications were administered. Staff 13 and 14 were not able to remember any incidents where the wrong medications were provided to the wrong resident. An interview on 6/10/13 at 2:00 pm with 10 (RNCM) revealed Staff 10 was involved with the investigation of the medication error. Staff 10 stated the nursing staff was expected to check the MAR for the right medication and right order, refer to the right page in narcotic book and check the identity of the residents. Staff 8 was expected to know the six rights of medication administration. Staff 10 (RNCM) was not aware of any other medication errors of the same type which occurred at the facility. Staff 10 stated the current facility system was a good system. Staff 10 stated Resident 1 sustained a femur fracture from the fall. Staff 10 (RNCM) demonstrated the facility's medication system. Staff 10 showed the MAR which included the resident's name, the physician's orders [REDACTED]. The medication cards were located in the locked portion of the medication cart. The cards of medications were sealed into individual doses and contained the resident's name and the physician's orders [REDACTED]. The staff would subtract the amount of medication given to determine the number of doses of medication remaining in the card. At the change of shift the amount of narcotic medications in the card would be matched against the narcotic drug book to ensure there was the same number of medications listed in both areas. Staff 10 stated it was the expectation of the nurses/CMAs to check to make sure the resident matched the medication/physician order. An interview on 6/10/13 at 3:35 pm with Staff 12 (Physical Therapy Assistant) revealed Staff 12 she attempted to assist Resident 1 with therapy on two occasions on 5/2/13. Staff 12 stated the first time she approached the resident in the morning she was not able to wake the resident up. Staff 12 stated Resident 1 spilled the breakfast meal "everywhere." Staff 12 stated prior to lunch she approached Resident 1 again about therapy. Staff 12 stated the resident was lying in bed and was able to talk though the resident was very lethargic. Staff 12 stated the resident was usually the first person in the therapy room between 8:00-8:30 am. An interview on 6/10/13 at 4:30 pm with Resident 1 revealed she/he had been admitted to the facility for therapy after a total right knee revision. Resident 1 stated she/he was given the wrong medication; she/he fell , fractured her/his femur and had to have another surgery. Resident 1 stated she/he was not able to remember anything after she/he was given the wrong medication. She/he stated she/he was not able to remember the fall and being transported to the local hospital. Resident 1 stated she/he was unable to remember what happened to her/him for a two day period. Resident 1 stated she/he originally planned to return home though the incident "really set her/him back with therapy." The resident stated she/he was not able to bear weight on her/his leg. Resident 1 stated said her/his family was in the process of moving and the incident really impacted their family. An interview on 6/10/13 at 5:00 pm and 6/11/13 at 2:00 pm with Witness 2 (Resident 1's family member) and Witness 3 (Resident 1's family member) revealed if the medication error had not happened Resident 1 would have been home. Witness 2 was tired of the resident being at the facility and not at home. Witness 3 stated the resident was not able to remember being given the wrong medications and the fall she/he had in the facility. An interview on 6/19/13 at 12:20 pm with Staff 6 (DNS) revealed Staff 8 (RN) failed to check the medication card with the order and with the resident. The resident sustained [REDACTED]. In an interview on 6/28/13 at 1:15 pm Witness 4 (Resident 1's physician) stated Resident 1 was usually cognizant and able to express her/his needs. Witness 4 was informed of the nursing note written on 5/2/13 indicating Resident 1 kept falling asleep while the nurse was talking with her, the resident unable to eat breakfast, had lethargy, resident difficult to arouse with period of shallow breathing between 10:00 am and 11:30 am though vital signs stable. Witness 4 stated from the information provided the resident had a change of condition. An interview on 6/28/13 at 1:26 pm with Witness 5 (Nurse with consulting pharmacy) revealed the resident received a "hefty" dose of [MEDICATION NAME]. An interview with on 6/28/13 at 2:52 pm with Witness 6 (Consultant Pharmacy) revealed the usual doses for elderly residents for [MEDICATION NAME] begin at 0.5 mg and gradually increase to the maximum dose of 2 mg in a 24 hour period. Witness 6 stated [MEDICATION NAME] was a short acting medication with the maximum effect of the medication was between 5-7 hours. Witness 6 was told the resident received the [MEDICATION NAME] at 2:30 am and Witness 6 stated the effectiveness of the medication should have tapered down between 8:00 and 9:00 am. Witness 6 stated each person reacted differently to medications. Witness 6 stated the resident received a large dose of [MEDICATION NAME] initially, was not accustomed to [MEDICATION NAME], so the effects of the medications were potentially longer for the resident. Witness 6 stated all of the nurses know the major side effect of [MEDICATION NAME] was sedation. Witness 6 stated [MEDICATION NAME] was a controlled substance and the provision of [MEDICATION NAME] without a physician's orders [REDACTED]. An interview on 6/28/13 at 4:43 pm with Staff 15 (CNA) revealed 5/2/13 was the second day Staff 15 provided care for Resident 1 though Staff 15 was familiar with the resident. Staff 15 stated the resident was usually out of bed for meals, gone to therapy and activities during the day. Staff 15 stated on 5/2/13 the resident wanted to stay in bed was very groggy. On 5/2/13, the resident refused to get up in the morning and ate her/his breakfast meal in bed. Staff 15 stated the resident ate a small portion of the meal independently and Staff 15 assisted the resident with a shower. Staff 15 stated the resident was able to stand up though her/his balance was poor. Staff 15 stated after the shower she assisted the resident in the smoking area. Staff 15 stated the resident was usually an independent with smoking though Staff 15 stayed with the resident for safety. Staff 15 stated the resident complained of being dizzy and wanted to lie down for a nap. Staff 15 stated she assisted the resident into bed. Staff 15 stated while she was on her lunch break, Staff 16 (CNA) saw the resident get out of bed and Resident 1 attempted to ambulate to the bathroom. Staff 16 assisted the resident to the bathroom and then assisted the resident back into bed. Staff 15 stated fifteen minutes after she returned from lunch break she heard noise around Resident 1's room and learned the resident fell . Staff 15 stated Staff 16 was very familiar with the resident. Staff 15 stated the resident was able to answer questions though she/he was different than her/his normal self. An interview on 6/28/13 at 6:10 pm Staff 16 (CNA) revealed on the morning of 5/2/13 Staff 16 saw Resident 1 "hobbling" around her/his bed. Staff 16 stated she provided the resident with the walker and assisted her/him into the bathroom. Staff 16 stated she provided the call light to the resident when the resident was finished in the bathroom. Staff 16 stated she provided care for Resident 1 on a regular basis and the resident was normally alert and oriented. Staff 16 stated the resident knew Staff 16 by name. Staff 16 stated on 5/2/13, the resident was "super" confused. Staff 16 was asked what she meant by "super" confused and she stated the resident kept dozing off, seemed drugged and did not know who Staff 16 was. Staff 16 stated the resident's balance was poor and she/he used the foot board of the bed and was walking on her/his right leg and the resident was not to put weight on the leg. Staff 16 stated the nurse was aware of the resident's confusion. Staff 16 stated she told Staff 15 the resident attempted to ambulate independently to the bathroom. Staff 16 stated when she returned from her lunch break she learned the resident fell in her/his room.

Based on interviews and record review it was determined the facility staff failed to appropriately administer medications for 1 of 5 sampled residents (#1) without a significant medication error. Resident 1 was given Resident 3's [MEDICATION NAME] (anti-anxiety medication) and as a result fell and sustained a right femur fracture requiring surgical repair. Findings include: "Conduct Derogatory to the Standards of Nursing Defined 851-045-0070 Nurses, regardless of role, whose behavior fails to conform to the legal standard and accepted standards of the nursing profession, or who may adversely affect the health, safety, and welfare of the public, may be found guilty of conduct derogatory to the standards of nursing. Such conduct shall include, but is not limited to, the following: (1) Conduct related to the client's safety and integrity:(o) Failing to dispense or administer medications, including [MEDICATION NAME], in a manner consistent with state and federal law." Resident 1 was admitted to the facility in April 2013 with [DIAGNOSES REDACTED]. The 5/2/13 Departmental Notes written at 7:17 am by Staff 8 (RN) indicated a medication error was discovered during the narcotic count at 6:50 am. The note indicated, on 5/2/13 at 2:30 am, Resident 1 was given two 1 mg tablets of [MEDICATION NAME] instead of two 2 mg tablets of [MEDICATION NAME] (narcotic pain medication) by Staff 8 (RN). Staff 8 indicated the resident was assessed and the resident was informed of the medication error. Departmental notes written on 5/2/13 at 11:55 am indicated Staff 9 (RN) heard an exclamation coming from Resident 1's room. The resident was found sitting on the floor next to her/his bed and was visibly upset. Staff 9 stated there was liquid noted on the floor around the resident on her/his legs and soaking her/his pants. Resident 1 stated "no one will tell me what's going on. I was going to the bathroom and I was peeing but there's water all over the floor." The resident denied pain initially though after 5 minutes the resident started to complain of severe left leg pain. The 5/2/13 Departmental Notes written by Staff 9 (RN) at 3:45 pm indicated at the beginning of the day shift the resident was noted to be lethargic, sleepy but arousable. Staff 9 (RN) indicated Resident 1 kept falling asleep when Staff 9 (RN) was talking with the resident. The notes indicated Resident 1 stated she/he was having trouble waking up and the resident was informed it was an effect of the [MEDICATION NAME]. The resident was noted to be unable to feed herself/himself breakfast. Resident 1 was noted to be lethargic though oriented and received a shower after breakfast. The resident was then assisted into bed and was sleeping at 10:00 am. Staff 9 documented she checked on the resident every 30 minutes and noted the resident was difficult to rouse, had periods of shallow breathing between 10:00 am and 11:30 am. The resident was transported to the local hospital emergency department on 5/2/13. The x-rays revealed the resident had a fractured right femur and required surgery to repair the fracture. Staff 6 (DNS) provided the 5/9/13 Employee Corrective Discipline Form signed by Staff 8 (RN). The form indicated Staff 8 failed to follow nursing standards of practice, failed to administer medications in a manner consistent with state and federal law, and did not follow the six rights of medication administration, (right resident, right medication, right dose, right route, right time and right documentation). The form indicated the failure to administer the correct medications contributed to the resident's fall with fracture. Staff 8 was terminated from employment on 5/9/13. An interview on 6/28/13 at 4:43 pm with Staff 15 (CNA) revealed 5/2/13 was the second day Staff 15 provided care for Resident 1 though was familiar with the resident. Staff 15 stated the resident was usually out of bed for meals, gone to therapy and activities during the day. Staff 15 stated on 5/2/13 the resident was very groggy, refused to get up in the morning and ate her/his breakfast meal in bed. Staff 15 stated the resident ate a small portion of the meal independently. Staff 15 stated she assisted the resident with a shower and Resident 1 was able to stand up though her/his balance was poor. Staff 15 stated the resident was usually an independent with smoking though Staff 15 stayed with the resident in the smoking area for safety. Staff 15 stated the resident complained of being dizzy and wanted to lie down for a nap. Staff 15 stated she assisted the resident into bed. Staff 15 stated while she on her lunch break, Staff 16 (CNA) saw the resident get out of bed to attempt to ambulate independently to her/his bathroom. Staff 16 assisted the resident to the bathroom and then assisted the resident back into bed. Staff 15 stated fifteen minutes after she returned from lunch break she heard noise around Resident 1's room and learned the resident fell . Staff 15 stated Staff 16 was very familiar with the resident. Staff 15 stated the resident was able to answer questions though she/he different than normal. An interview on 6/28/13 at 6:10 pm with Staff 16 (CNA) revealed the morning of 5/2/13 Staff 16 saw Resident 1"hobbling" around her/his bed. Staff 16 stated she provided the resident with a walker and assisted her/him into the bathroom. Staff 16 stated she provided the call light to the resident to call the staff when Resident 1 was finished in the bathroom. Staff 16 stated she provided care for Resident 1 on a regular basis and the resident was normally alert and oriented. Staff 16 stated the resident was able to identify Staff 16 by name. Staff 16 stated on 5/2/13 the resident was "super" confused. Staff 16 was asked what she meant by "super" confused and she stated the resident kept dozing off, seemed drugged and did not know who Staff 16 was. Staff 16 stated the resident's balance was poor and she/he used the foot board of the bed and was walking on her/his right leg and the resident was not to bear weight on the leg. An interview with on 6/28/13 at 2:52 pm with Witness 6 (Consultant Pharmacy) revealed [MEDICATION NAME] was a controlled substance and the provision of [MEDICATION NAME] without a physician's orders [REDACTED]. Refer to F-333

Based on interviews and record review, it was determined the facility failed to implement policy and procedure regarding incident occurrence reporting/response for 1 of 1 sampled resident (#2). Staff 2 (CNA) provided care for the resident. The resident complained of pain and was unable to use her/his left arm. Resident 2 stated a caregiver grabbed and twisted her/his arm. Staff 2 acknowledged he grabbed the resident's wrists during care and the consequence included Resident 2 sustained a fractured wrist during care and was sent to the local hospital; the incident was not reported by the care giver. Findings include: The facility's Abuse Prevention Policies and Procedures under "Reporting and Response: 1. Employees are to immediately report to their onsite supervisor any alleged incidents of abuse, neglect, involuntary seclusion, and/or misappropriation of resident's property...." Resident 2 was admitted to the facility in June 2010 with [DIAGNOSES REDACTED]. The 4/28/13 Departmental Notes written at 8:30 am by Staff 1 (LPN) indicated Staff 2 (CNA) reported Resident 2's incontinent brief was changed at 6:30 am. Staff 2 stated the resident tried to scratch Staff 2 and Resident 2 scratched her/his own arm. Staff 2 reported the resident was yelling nasty words at Staff 2. Staff 1 assessed the resident and discovered the resident sustained [REDACTED]. Staff 1 notified the resident's physician and provided treatment as ordered. The 4/28/13 Departmental Notes written at 12:33 pm by Staff 4 (LPN) indicated Staff 5 (CNA) stated Resident 2 complained of pain and could not use her/his left arm. Staff 4's assessment of the resident's left wrist and forearm area determined the area was tender to the touch; there was some swelling and possible bruising. Staff 4 determined the resident's grip was weaker on the left than the right. Staff 4 documented the resident stated "that boy grabbed and squeezed then twisted it." Staff 4 obtained physician's orders [REDACTED]. Staff 4 documented she informed Staff 6 (DNS) of the possible fracture. The 4/28/13 local hospital x-ray report indicated the resident had decreased bone mineral density and [MEDICAL CONDITION] changes of the wrist and elbow. The x-ray revealed the resident had an acute [MEDICAL CONDITION] wrist from trauma. The 4/28/13 local police department report indicated the resident was interviewed by the local police department at the local hospital emergency department. The resident was asked what happened to her/his arm and Resident 2 stated " he (caretaker) broke my arm with his hand ...He really did a good job on me ...." The resident was asked how bad her/his wrist hurt when it happened and the resident stated it was "screaming bad." Staff 6's (DNS) investigation of the 4/28/13 incident indicated Staff 6 (DNS) had been informed by Staff 4 (LPN) of Resident 2's injury to her/his left wrist and the resident's complaint of Staff 2 (CNA) grabbing and twisting her/his arm. Staff 6 indicated Staff 2 (CNA) was interviewed and he was asked about the care he provided for Resident 2 on the night shift. Staff 2 stated he wrapped the resident in a bath blanket and Resident 2 became combative while changing the incontinent brief. Staff 2 stated the resident started to flail around with her/his arms and he stated he held the resident's arm to prevent himself from being scratched by the resident. Staff 2 stated the resident stated her/his arm hurt though he was unable to state which one. Staff 2 stated he informed the charge nurse (Staff 1) of the skin tear. On 4/29/13 Staff 2 (CNA) completed a written description of the incident. "At approximately 5:05 am on 4/28/13 I was changing Resident 2's brief. About halfway through the process Resident 2 was saying expletives to me. I grabbed her/his wrists and she/he jerked away. I heard a slight cracking sound as she/he pulled out of my grasp. She/he then complained of pain in her/his arm and became docile. I finished the brief change and then noticed a slight scratch on the inside of her/his right forearm. I reported to Staff 1 (LPN) what had happened and told Staff 1 about the scratch on Resident 2's arm. I did not report the complaint of pain. About 10 minutes later Staff 1 (LPN) and I went into Resident 2's room and Staff 1 looked at the scratch. Resident 2 complained of pain in her/his left arm ...." A 4/29/13 type written interview conducted by Staff 7 (Administrator) with Staff 2 (CNA) revealed Staff 2 stated Resident 2 started to attack and yell at Staff 2. Staff 2 stated he reached out to stop the resident and grabbed her/his wrist. Resident 2 then pulled her/his arm back and Staff 2 heard a cracking sound. Staff 2 completed the change and noticed Resident 2 had scratched her/his arm so Staff 2 (CNA) went to get the charge nurse (Staff 1). Staff 2 showed Staff 1 the scratches and informed her of the incident, when Staff 1 (LPN) started to look at the scratches Staff 2 (CNA) left the room to complete the rest of his rounds. Staff 7 (Administrator) asked Staff 2 (CNA) why he grabbed the resident's wrist. Staff 2 responded "It was a reaction, (Resident 2) was trying to attack me, it was not very long, and when she/he pulled away I heard cracking." Staff 7 (Administrator) asked Staff 2 if Resident 2 reacted this way in the past, Staff 2 said "A couple of times, but not like this one, this time was really violent." A 5/2/13 Employee Corrective Discipline Form completed by Staff 6 (DNS) indicated Staff 2 (CNA) was terminated from employment. The form indicated during the investigation it was determined Staff 2 was assigned to care for Resident 2. Staff 2 acknowledged he cared for the resident at the time of the incident and Staff 2 reported the resident sustained [REDACTED]. Resident 2 jerked away and Staff 2 heard a slight cracking sound and the resident complained of pain. Staff 2 (CNA) did not report the complaint of pain nor the cracking sound to Staff 1 (LPN). Staff 6 documented "a primary responsibility of the CNA is to ensure the safety of the residents. Another is to report timely and accurately to the charge nurse on resident conditions. Conduct of grabbing a resident's wrists (rather than backing away) hearing a crack, the resident then complaining to him of pain and then not reporting accurately to the charge nurse is very unacceptable ...." An interview on 6/19/13 at 12:26 pm with Staff 6 (DNS) revealed the facility regularly provided in-services regarding abuse and felt this was an isolated occurrence. Since the 4/28/13 incident the facility provided additional in-services for the rest of the staff to prevent a reoccurrence.

Based on observation, interview and record review it was determined the facility failed to prevent the development of a pressure ulcer and promote the healing of a pressure ulcer for 1 of 4 residents (#200) who had pressure ulcers. The resident developed a Stage III heel pressure ulcer (full-thickness tissue loss) while at the facility and the resident's pressure ulcer worsened. Findings include: The National Pressure Ulcer Advisory Panel (NPUAP) defined an unstageable wound as:"full thickness tissue loss in which actual depth of ulcer is completely obscured by slough (yellow tissue) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, true depth cannot be determined. It will be either Stage III or Stage IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed." The NPUAP defined a deep tissue injury (DTI): "purple or maroon localized area of discolored skin or a blood-filled blister due to damage of underlying soft tissue from pressure and/or shearing. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler than adjacent tissue." Resident 200 was admitted to the facility in January, 2013 with [DIAGNOSES REDACTED]. The In-Room Care Plan dated 1/30/13 directed staff to float the resident's heels while in bed and reposition the resident every two hours. The Braden Scale (tool used to assess pressure ulcer risk) dated 1/30/13 indicated the resident was at high risk for skin breakdown. The MDS dated [DATE] indicated there was no evidence the resident had a pressure ulcer (PU). The Skin Progress Sheet dated 2/7/13 documented the resident's unstageable left heel PU was first identified on 2/7/13. The PU was described as a closed, dark area and measured 3.5 cm x 4.0 cm. The Physician's Telephone Order dated 2/7/13 directed staff to protect and monitor the resident's left heel PU from further skin breakdown. The orders included the application of barrier film to the resident's unstageable left heel ulcer and the use of heel boots. The Skin Progress Sheet dated 2/24/13 described the resident's left heel as a "DTI (deep tissue injury)." The Nursing Notes (NN) dated 2/26/13 during the evening revealed the resident's left heel was "showing more breakdown." A Physician's Telephone Order dated 2/26/13 directed staff to soak the resident's feet in Epsom salts twice a day for 15 minutes. The Physician Interdisciplinary Progress Note dated 2/28/13 indicated the resident's [MEDICAL CONDITION] was assessed. There was no documentation pertaining to the resident's left heel pressure ulcer. The NN dated 3/1/13 revealed the resident's "heel blister on left heel now open. New wound care orders in place. Soaking feet in Epsom salts 15 minutes...Patient states the left heel is more painful now that blister is open." The NN dated 3/1/13 indicated a podiatrist provided the resident's toe nail care on 2/26/13 and the physician ordered Epsom salt foot soaks. The note indicated the resident's open skin area on the left heel occurred two days after the Epsom soak treatments began. The Physician's Telephone Order dated 3/1/13 included: "(Left) heel blister-clean with NS (normal saline), may still soak with Epsom salts for week long period ordered." The order included a daily silver alginate application over the area and a padded dressing. The NN dated 3/2/13 indicated the resident's left heel PU was an "open wound-3 cm open with DTI in center." The NN dated 3/3/13 documented: "Dc'd (discontinued) Epsom salt soak related to increase in maceration on the left heel. Left heel severely macerated and open. Peri-wound almost 100% macerated within 1 cm of wound, skin separating from dermis and falling off. Pt (Resident 200) reports 5/10 pain with pressure. There was a small amount of bleeding along wound edge. Barrier film applied to the peri-wound with alginate and foam dressing..." The Skin Progress Sheet dated 3/4/13 identified the resident's left heel as a Stage III PU, 2.2 cm round and 0.1 cm deep. The skin sheet indicated slough (necrotic/avascular tissue in process of separating from the body and often light-colored tissue) was present in the center of the wound, measuring 1.2 by 1.1 cm round. The skin sheet identified a dark-colored area beneath the slough and staff assessed the resident's left heel PU as "worsened." The Physician's Telephone Order dated 3/4/13 directed staff to arrange a wound center consultation for the care of the left heel PU. The NN dated 3/8/13 through 3/9/13 documented the resident's left heel was moderately painful during dressing changes and the resident's left heel PU limited the resident's ability to ambulate. The Skin Progress Sheet dated 3/11/13 indicated the resident's left heel PU was slightly larger than the previous week's measurement. The Physician Interdisciplinary Progress Note dated 3/11/13 revealed the resident's left heel ulcer was "boggy." The NN dated 3/15/13 indicated eschar (black, devitalized tissue) was noted in the wound bed. The Wound Clinic Consultation note dated 3/22/13 documented staff were to leave the resident's left heel PU open to air and apply [MEDICATION NAME] BID. The note indicated staff were to prevent pressure to the resident's left heel and it was to be kept dry. On 3/27/13 at 10:00 am Resident 200 was observed sitting in a wheelchair with the leg rests. The resident indicated s/he preferred to be out of bed as much as possible and when s/he was in bed staff put on the padded boots. The resident agreed to show the Surveyor her/his left heel and a quarter-size necrotic area was observed. On 3/28/13 at 3:30 pm Staff 7 (RN) was shown the Epsom salt foot soak order. She stated the podiatrist cut the resident's toenails, the toenails were bleeding afterward and Epsom salt foot soaks were ordered. Staff 7 stated she knew the resident had a left heel PU and she did not question the Epsom salt order. Staff 7 indicated the Epsom salt solution could help prevent any infection to the toenails. On 3/28/13 at 3:40 pm Staff 31(Physician) stated she signed the telephone order on 3/1/13 for the resident to continue Epsom salt foot soaks and was not aware the left heel blister had opened. On 3/28/13 at 4:45 pm Staff 20 (RNCM) indicated the resident's left heel area had a darkened skin discoloration which was a suspected DTI (deep tissue injury). She indicated the resident's left heel blister opened and the open area was pink and clean; the open area became more of a wound later. Staff 20 indicated a podiatrist cut the resident's toe nails and ordered the Epsom salts. Staff performed the foot soaks for several days and the Epsom salt treatment was discontinued. She stated the resident elevated both legs on a pillow while in bed, wore heel protectors and was advised not to wear shoes. She indicated staff should not have soaked the resident's left heel.

Based on witness and staff interviews; and hospital and facility records it was determined the facility failed to implement a care plan fall intervention for 1 of 3 (# 1) sampled residents who had a fall. Resident 1 fell and suffered a hip fracture. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a ground level fall on 1/5/11 and was diagnosed in the ER with a Vancouver Type A (non displaced) right hip fracture on 1/6/11. The resident no longer resides at the facility. The Initial Treatment Plan for Rehabilitation dated 12/17/10 indicated the resident had poor safety awareness due to her cognitive level. The Comprehensive Care Plan dated 1/3/11 indicated the resident's bed and wheelchair alarms would continue to be used. Resident 1's Nursing Notes dated 1/5/11 indicated at 2:40 pm the CNA notified the RN when the resident was lying on the floor near her/his wheelchair. The RN assessed the resident as alert and had no apparent injury at that time. Documentation in the notes at 10:30 pm revealed "...later when asked if she has pain, nodded and held on to her right thigh." The notes included the RN's notification of these changes to the physician, with the direction given to further assess the resident and plan for the resident's Xray the next day. The facility's Incident Report dated 1/5/11 indicated Resident 1 was found on the floor by a CNA around 2:40 pm. The RN assessment revealed the resident had a non-injury fall and did not show any facial grimacing at that time. The resident's January, 2011 MAR documented the resident received his/her scheduled Norco (a narcotic pain medication) at 2:00 pm on 1/5/11. Norco ordered every four to six hours PRN was administered to the resident at 5:30 pm and 11:30 pm on 1/5/11. There were no prior PRN doses of Norco recorded as given on the resident's January, 2011 MAR. The Nursing Notes dated 1/6/11 at 9:30 am revealed the resident was unable to bear weight on his/her right leg and displayed increased signs of pain. The NP (Nurse Practitioner) was notified and ordered the resident's transport to the ER for evaluation. The resident's Emergency Department Report dated 1/6/11 at 10:16 am documented Resident 1 complained of severe right hip pain and received Fentanyl (analgesic narcotic patch). The physician documented the resident's [DIAGNOSES REDACTED]." The hospital's Imaging Report dated 1/6/11 included the radiologist's impression of the resident's right hip Xray as an "osteoporotic (porous and brittle bone subject to fracture) right hip bone...suspect nondisplaced fractures through the base of the great trochanter of the right femur." The Treatment Encounter Notes dated 1/5/11 indicated the resident's PT session was interrupted when the resident required incontinence care in her/his room. Staff 8 (Physical Therapist Assistant, PTA) documented the resident's transfer to bed, bed alarm activation and the CNA was informed Resident 1's brief needed to be changed. On 1/24/11 at 8:50 am Witness 1 (Complainant) stated a facility nurse informed her/him Resident 1's wheelchair alarm was not turned on at the time of the resident's fall on 1/5/11. On 1/24/11 at 1:15 pm Staff 2 (Registered Nurse Care Manager, RNCM) stated her investigation of Resident 1's fall on 1/5/11 included interviews with Staff 8 (PTA) and Staff 7 (CNA). She stated Staff 8 told her the resident was transferred to bed, the bed alarm was activated and the day shift CNA was told the resident's brief needed to be changed. Staff 2 stated Staff 7 told her she transferred Resident 1 into her/his wheelchair but was "unable to remember placing alarm." Staff 2 stated the resident was found on the floor by Staff 4 (CNA) at 2:40 pm during her initial evening rounds on 1/5/11. On 1/24/11 at 2:35 pm Staff 4 (CNA) stated she discovered Resident 1 lying on the floor near her/his wheelchair in her first visual check of the residents on 1/5/11. She recalled the resident's wheelchair pressure alarm was turned in the off position and immediately informed the RN. Staff 4 stated Resident 1's care plan directed the staff to be certain the resident's bed and wheelchair alarms were on at all times. On 1/24/11 at 2:30 pm Staff 5 (RN) stated on 1/5/11 the CNA told her Resident 1 was lying on the floor, her assessment revealed the resident's body was in good alignment and the resident did not display signs of pain. Staff 5 stated the physician was notified the resident fell at 2:40 pm. On 1/25/11 at 11:00 am Staff 6 (Rehabilitation Manager) recalled Staff 8 (PTA) told her what happened just before Resident's fall on 1/5/11. She stated Staff 8 no longer worked at the facility. On 1/26/11 at 7:20 am Staff 7 (CNA) recalled on 1/5/11 she transferred Resident 1 into the wheelchair and told Staff 8 the resident was in the wheelchair. Staff 7 stated her shift was over and she left for the day. Staff 7 stated she could not say for certain whether she remembered to activate the resident's wheelchair alarm just prior to the resident's fall.