Every finding on record at Heritage Center

Based on record review, staff interviews, and family interviews, the facility failed to keep the resident environment as free of accident hazards as possible, by not ensuring Resident #157 had assistive devices in place to prevent avoidable accidents. The State Agency (SA) determined that the potential for harm occurred on 12/24/25 when Resident #157 changed rooms and his bed rails did not go with him. Actual harm occurred on 12/26/25 when Resident #157 had a fall from bed resulting in a confirmed brain bleed. The facility was back in compliance on 12/30/25 after the last current staff member had been re-educated. This failed practice was found true for (1) one of (3) residents reviewed for fall prevention safety during the Complaint Survey. Resident identifier: #157. Facility Census: 156.Findings include:a) Resident #157 A record review on 05/19/26 at 9:40 AM, of the reportable log from 11/2025 to present found a reportable for Resident #157 dated 12/26/25 for a fall with major injury.Further review of the reportable five day follow-up summarizes the incident as follows: On 12/26/25, (Resident #157 name) had an unwitnessed fall with potential for serious bodily injury. A report was made to OHFLAC, APS, and Ombudsman. An investigation was initiated.During the investigation, the staff caring for (Resident #157 name) were interviewed and provided the following information: (Resident #157 name) was found by staff lying on the floor on his stomach beside his bed. The nurse was notified and a head to toe evaluation and vitals were completed. (Resident #157) was unable to recall what had happened due to poor cognition, which is consistent with his baseline. He had no complaints of pain or visual injuries noted. Staff noted that (Resident #157) bed was in the lowest position with call light in reach. (Resident #157 was assisted back to bed by staff x2 via mechanical lift. The facility provider was notified and neuro checks were started. His health care surrogate was notified and later in the morning came to visit (Resident #157 name). He requested for (Resident #157) to receive x-rays, but did not want to wait for an outside x-ray provider to be in the facility. He ultimately requested for him to be sent to the ER for evaluation. The facility provider was notified and (Resident #157) was sent to the ER for further evaluation per the HCS request. It was noted during the investigation that the night shift nurse had last checked on (Resident #157 name)around 5:30AM and at that time he was asleep in bed.While at the hospital, (Resident #157 name) received a CT of spine cervical w/o contrast, CT spine lumbar trauma, CT spine thoracic trauma, and CR port chest single. The results showed an intracranial hemorrhage that was present during a recent hospitalization before admitting to (Current Center name). It also showed a small left occipital hemorrhage without significant mass effect or shift. The CT spine showed a T2 compression deformity that was present on a CT from 11/25. (Resident #157 name) was admitted to the ICU for q1 neuro checks. He remains in the hospital at this time.The IDT team met to review the fall, (Resident #157 name) was found on the floor of his room. He had not pain or injuries noted at the time of the fall. His Health Care Surrogate was notified and requested for the resident to be sent to the ER for further evaluation. (Resident #157 name) was admitted to the ICU. Should (Resident #157 name) return to our facility, a care plan intervention has been added to include a perimeter mattress to his bed. This incident is verified for an unwitnessed fall with serious bodily injury. This incident is not related to abuse or neglect.A review on 05/19/26 at 10:15 AM found an order for Resident #157 dated 12/19/25 that read as follows: Bed rails 1/2 as an enabler for turning and repositioning in bed.Further record review revealed a Bed Safety Evaluation dated 12/19/26, under section 2a. That read as follows: Rails at top of bed to aid in turning and repositioning and be more safe when exiting the bed.Resident #157 was moved from room [ROOM NUMBER] to room [ROOM NUMBER] on 12/24/25.Further record review of the eInteract Change in Condition Evaluation, reveals that Resident #157 had a fall from bed on 12/26/25 and was sent to the emergency room per Health Care Surrogate (HCS) request. There is no mention of the side rails being in use when the fall occurred from bed. Physician's emergency room ReportA review on 05/19/26 at 10:30 AM, found a Physician's emergency room report, under Patient chief complaint reads as follows: Fall from bed, head trauma The patient is an [AGE] year old male with a past medical history significant of CAD, CHF, diabetes mellitus, hypertension, hyperlipidemia, ischemic cardiomyopathy, and prostate malignancy who presents to the ED for evaluation after falling from his bed at a local nursing facility. According to EMS, the patient fell from his bed, striking his head and landing on his left shoulder, however nursing facility staff did not witness the incident. They told EMS that the patient is more drowsy currently than at his baseline. He is not on any anticoagulants. Further history is limited at this time due to patient's ability to provide history.Radiographic imaging of CT to head or brain without contrast found the following:Interval hemorrhage within the left occipital lobe.Marked improvement in previous intraventricular hemorrhage and larger more anterior focus of intraparenchymal hematoma left optical lobe.During a phone interview on 05/19/26 at 11:45 AM, the Health Care Surrogate (HCS) for Resident #157 said that his dad was transferred to this nursing home on December 18th. The family requested the facility to use side rails and fall mats for his bed due to past fall history. The side rails were placed on his bed. His dad had a room change and the side rails and floor mats did not go with him. I got a call that my dad had fallen and the facility said there were no injuries. When I got there, my dad was telling me how much he hurt. I also noticed that no side rails were on his bed at this time. I had them send him to the Emergency Room, and he had a brain bleed and was put in ICU. From the hospital he went to the Hospice house on January 16th and passed away on January 17th.During an interview on 05/19/26 at 2:00 PM, The State Agency (SA) asked the Administrator to tell us about the incident with Resident #157. The Administrator said that it is always standard practice when a resident moves rooms that the bed with all of its equipment goes with them so nothing gets missed. With this particular move the Resident and his roommate had an altercation and a bed next door was empty, and the resident moved themselves to that bed. The administrator confirmed that the side rails were not moved with this resident.The administrator further said that they immediately put a plan in place to ensure this does not happen again. A review on 05/19/26 at 3:15 PM revealed a Plan In Place (PIP) that is as follows:The Director of Nursing (DON) completed an audit on 12/29/25 to ensure residents have a bed safety evaluation and a bed safety evaluation follow up, if bed rails indicated, obtain order, care plan and consent obtained from resident/responsible party with any corrective action immediately upon discovery.The maintenance/designee conducted an audit on 12/29/25 to ensure correct installation of bed rails, including adherence to manufacturer's recommendations and/or specifications with any corrective action immediately upon discovery.Re-education was provided by the DON/Designee to licensed nurses and maintenance department on or before 12/30/25 regarding the bed safety evaluation will be completed upon admission, readmission, quarterly change in bed or mattress, and with a significant change in condition in the patient's self-performance of bed mobility. If indicated for bed rails in use, an order, consent from resident/responsible party to be obtained, and care planned. A post-test to validate understanding. Any nursing staff not available during this time frame will be provided re-education, including post test by DON/designee prior to the beginning of the next shift to work. New nursing staff will be provided education, including post-test during orientation by the DON/designee.Re-education was provided by the NHA/Designee to the maintenance department on or before 12/29/25 regarding the Maintenance will ensure inspections (audits) will occur at a minimum of annual and with any change in bed frame, mattress, or bed rail with post-test to validate understanding. Any maintenance staff not available during this time frame will be provided re-education, including post-test by NHA/designee prior to the beginning of the next shift to work. New maintenance staff will be provided education, including post-test during orientation by the NHA/designee.The DON/designee will monitor starting on 12/29/26 new admissions/readmissions, any resident with a new mattress or bed or a significant change to ensure bed safety evaluation is completed with order for bed rails, consent, and care plan daily for 2 weeks including weekends and holidays, then 5 times a week for 4 weeks, then 3 times a week for 4 weeks, then randomly thereafter.The Maintenance Director/designee will monitor starting on 12/29/26 residents with any change in bed frame, mattress, or bed rail will be inspected and documented in TELS daily for 2 weeks including weekends and holiday then 5 times a week for 4 weeks, then 3 times a week for 4 weeks, then randomly thereafter.Further review of the PIP, revealed that all of the above action had been completed by 12/30/25.

Based on observation and staff interviews, the facility failed to provide a safe, clean, comfortable, homelike environment. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census: 156. Findings Include:a) 3rd floor dining roomAn observation on 05/19/26 at 8:45 AM of the 3rd floor dining room found a set of cabinets. The bottom cabinet was full of trash such as wrappers, napkins, etc., and lots of food crumbs. The drawer on the right side was stuffed with a dirty brief.During an interview on 05/19/26 at 9:00 AM, The Administrator and Director of Nursing both confirmed that the cabinet was dirty. The DON stated, I am so embarrassed.b) 2nd floor lounge areaAn observation on 05/19/26 at 10:00 AM, of the 2nd floor found a resident lounge. In the corner beside the pop machine, there were two broken pictures on the floor along with a headboard of a bed, several leg rests, two tubes of Zinc oxide paste, and wheelchair cushions.During an interview on 05/19/26 at 10:20 AM, the Director of Nursing (DON) confirmed the items should not be there and stated, I will get someone to put this stuff up.c) Homestead (Alzheimer's Unit)An observation on 05/19/26 at 10:30 AM, of the Homestead (Alzheimer's Unit),revealed in the dining room a plate in the sink, that was accessible to residents that was full of chewed up meat, peas and a half eaten roll . Inside The refrigerator in the unit was covered in a brown red like substance on the bottom with what appeared to be dirty paper towels stuck to itDuring an interview on 05/19/26 at 10:45 AM, the Homestead Program Director stated, That is gross. I will take care of it.

Based on interviews and record review, the facility failed to ensure dependent residents had assistance with activities of daily living regarding assistance with eating and showers. Resident identifier: #20, #102, and #112. Facility census: 156. Findings include:a) Resident #20On initial tour of facility on 05/19/26, Resident #20 was observed in the third floor dining room with a tray of food in front of him at 8:49AM. The tray ticket designated the resident as requiring assistance with feeding. The food on the tray was cold and the oatmeal was congealed. Reported to Director of Nursing (DON) at 9:05AM, who confirmed Resident #20 has not been assisted with eating. A new tray was ordered and was delivered at 9:22 AM.b) Resident #102Resident #102 was observed at 9:37 AM with an uneaten breakfast tray at bedside. Her ticket indicated she required assistance with feeding. At 9:41 AM, it was confirmed by Licensed Practical Nurse (LPN) #1 that Resident #102 had not been assisted with feeding. She stated she thinks that is an old order and she no longer required assistance. c) Resident #112During an interview with Resident #112's daughter at 9:10AM, she reported that she and her sisters come to the facility daily to assist with feeding Resident #112 her breakfast and her dinner as this has been an issue with her mom not being fed. She stated there were multiple times she would come to the facility and find the breakfast tray on the bedside table with cold food. Resident #112 was observed on 05/20/26 at 12:30 PM with full lunch tray on bedside table with no assistance being provided. An interview with Nurse #23 confirmed no assistance was provided for Resident #112 to eat her meal at 12:39 PM on 05/20/26. A review of the care plan for Resident #112 shows an intervention that reads, provide resident with partial/moderate assist for eating.

Based on interview and record review, the facility failed to provide and document sufficient preparation and orientation to Resident #158 and caregiver to ensure safe and orderly discharge from the facility. This was true for one (1) of three (3) residents sampled for discharges during the complaint investigation. Census: 156 Resident identifier: #158Findings include:a) Resident #158During a phone interview with Resident #158's daughter at 4:00PM on 05/19/26, she stated the facility contacted her two (2) hours after the appeal deadline to notify her of discharge plans, which occurred the day before her father's discharge. Complainant states at that time, the facility representative also said they did not yet have the admission paperwork signed and asked if they could email her the paperwork. She reports the facility representative stated that they had seen her brother several times, but was never able to catch him for the paperwork. She stated she was very unhappy with the social worker who called with this information and asked to speak to someone above her or be given the contact information for complaints, but that was not provided. She also reported that her father had an ostomy, a catheter, and wounds, and the family received no education on managing these conditions.A record review of the Notice of Medicare Non-Coverage (NOMNC) reveals the facility attempted to call Resident #158's son four (4) times on 04/03/26, but was unable to reach him. The facility was unable to provide proof of mailing the NOMNC nor that they attempted to contact his daughter on this day. Per the Physician Determination of Capacity dated 03/06/26, Resident #158 did not have capacity to understand or make medical decisions. The Discharge Transition Plan shows the discharge destination as home alone and states the resident is responsible for self and makes own decisions. It also indicates Resident #158 needs assistance with toileting, household tasks, and transfers from bed to chair. A general progress note dated 04/07/26 at 1:09PM states the following: Resident to [discharge] DC home today. resident educated on all current wounds noted and treatments to be provided, resident able to verbal repeat back treatment orders in place and expressed verbal understanding regarding current wound status and treatments. A review of the Durable Power of Attorney paperwork shows Resident #158's son as the primary power of attorney (POA) and the daughter/complainant as the alternate health care agent. A Non-Completion Affidavit also shows that the admission packet dated 04/30/26 had not been signed.In an interview with Specialist-Social Services #253 at 9:10 AM on 05/20/26, she stated when she attempted to reach Resident #158's son initially, she did not have any other numbers available. She stated she found the daughter's number on the paperwork in the chart on 04/07/26 which is when she called her. She also stated that to her knowledge, the family was not educated on wound care or ostomy/catheter care which caused her to send an Adult Protective Services referral upon discharge. A review of the Post Discharge Follow-up form reveals Resident #158 was admitted to the VA hospital the day after discharge from the facility.

Based on resident interview, record review, and staff interview, the facility failed to provide activities of daily living, specifically showers, to dependent residents. This deficient practice had the potential to affect one (1) of six (6) residents reviewed for the care area of activities of daily living. Resident Identifier: #34. Facility census: 157. Findings included: a) Resident #34 On 09/29/2025 at 12:50 PM, Clinical Registered Nurse (RN) #206 stated the facility did not have a policy and procedure related to resident showers. She stated residents are given two (2) showers a week unless residents refuse showers or residents would like more than two (2) showers a week. During an interview on 09/22/2025 at 9:11 AM, Resident #34 stated she was supposed to get a shower twice a week but only received a shower every three (3) or four (4) weeks. Review of Resident #34's comprehensive care plan showed the resident required assistance for activities of daily living care due to limited mobility and cerebrovascular accident. Review of the facility's shower schedule showed Resident #34 was scheduled to receive showers on Monday and Thursdays every week. Review of Resident #34's bathing task reports for 09/01/25 through 09/23/25 showed no showers documented for the time period. On 09/24/25 at 2:24 PM, Registered Nurse (RN) #138 stated the resident's bathing task reports were inaccurate. RN #138 stated showers were also documented on handwritten documents in the shower book. RN #138 provided handwritten shower book documentation showing Resident #34 received a shower on 09/22/25. RN #138 stated the shower book showed no other showers for the time period. On 09/24/2025 at 3:48 PM, the Director of Nursing confirmed there was no documentation the resident had received or been offered twice weekly showers. No further information was provided through the completion of the survey.

Based on record review, resident interview, and staff interview the facility failed to ensure a physician order was correctly entered into the medical record. Additionally, the facility failed to ensure insulin was administered in accordance with professional standards of care. There was no order to hold the resident's medication for fingerstick blood glucose less than 150. These were random opportunities for discovery throughout the Long-Term Care Survey Process. Resident identifiers: #122 and #99. Facility census: 157.Findings included: a) Resident #122 During a review, on 09/30/2025 at 9:45 AM, the following physician order was found in Resident #122's electronic medical record: -CBC (Complete Blood Count) Q4 months (every four months) [for] anemia/coag (coagulant) use Feb/May/Aug. CMP (Comprehensive Metabolic Panel) Q4 months (every four months) [for] HTN (Hypertension) Feb/May/Aug . During an interview on 09/30/25 at 9:51 AM, the Director of Nursing acknowledged that February, May, and August were only three (3) month intervals and did not accurately reflect a four month timespan. b) Resident #99 Review of Resident #99's physician's orders showed an order written on 09/13/24 for the following insulin injection: Admelog SoloStar Subcutaneous Solution Pen-Injector 100 Unit/ml [milliliters] (insulin Lispro). Inject 25 unit [sic] subcutaneously before meals and at bedtime for DM2 [diabetes type II] Warning! Confirm patient. Insulin pens are for use in one patient only. Notify provider if blood sugar is < [less than] 70 or > [greater than] 400. Review of Resident #99's Medication Administration Record (MAR) for September 2025 showed the Admelog insulin was not given on the following dates at the following times: - 09/02/25 at 7:30 AM; the resident's blood glucose level was 134 - 09/04/25 at 9:30 PM; the resident's blood glucose level was 145 - 09/05/25 at 7:30 AM; the resident's blood glucose level was 123 - 09/05/25 at 11:30 AM; the resident's blood glucose level was 123 - 09/06/25 at 7:30 AM; the resident's blood glucose level was 118 - 09/07/25 at 11:30 AM; the resident's blood glucose level was 124 - 09/07/25 at 4:30 PM; the resident's blood glucose level was 144 - 09/08/25 at 7:30 AM; the resident's blood glucose level was 122 - 09/09/25 at 4:30 PM; the resident's blood glucose level was 148 - 09/10/25 at 7:30 AM; the resident's blood glucose level was 113 - 09/10/25 at 4:30 PM; the resident's blood glucose level was 97 - 09/11/25 at 7:30 AM; the resident's blood glucose level was 121 - 09/11/25 at 11:30 AM; the resident's blood glucose level was 131 - 09/12/25 at 7:30 AM; the resident's blood glucose level was 130 - 09/13/25 at 4:30 PM; the resident's blood glucose level was 140 - 09/15/25 at 4:30 PM; the resident's blood glucose level was 140 - 09/16/25 at 7:30 AM; the resident's blood glucose level was 147 - 09/18/25 at 7:30 AM; the resident's blood glucose level was 148 - 09/20/25 at 4:30 PM; the resident's blood glucose level was 98 - 09/21/25 at 7:30 AM; the resident's blood glucose level was 129 - 09/22/25 at 7:30 AM; the resident's blood glucose level was 144 - 09/22/25 at 4:30 PM; the resident's blood glucose level was 144 - 09/23/25 at 7:30 AM; the resident's blood glucose level was 120 - 09/24/25 at 7:30 AM; the resident's blood glucose level was 109 The MAR gave the notation WR on these dates at these times. On 09/24/2025 at 3:45 PM, the Director of Nursing (DON) stated WR means no coverage. She acknowledged there were no parameters based on blood glucose levels associated with this insulin order. The DON stated sometimes Resident #99 refused medication based on her blood glucose level, but she acknowledged refusals should have been documented. On 9/24/2025 at 4:00 PM, Corporate Clinical Registered Nurse (RN) #206 stated she had spoken to one of the nurses who had held Resident #99's insulin. The nurse stated he was used to orders for this insulin stating to hold the insulin for a blood glucose level less than 150. RN #206 stated the physician had been notified of the situation and Resident #99's Admelog insulin order was going to be modified to include instructions to hold the insulin for blood glucose less than 150. No further information was provided through the completion of the survey process.

Based on record review and staff interview, the facility failed to ensure assessment and treatment of pressure ulcers in accordance with professional standards of treatment. This deficient practice had the potential to affect one (1) of eight (8) residents reviewed for the care area of pressure ulcers. Resident Identifiers: #164. Facility census: 157. Findings included: a) Resident #164 The facility's policy titled, Skin Integrity and Wound Management, with effective date 07/01/01 and revision date 09/15/25, stated wound evaluation would be completed upon admission or readmission. The policy also stated the treatment interventions needed would be identified. Resident #164 was admitted to the facility on [DATE]. A skin check was initiated on 03/28/25 at 7:33 PM and signed by the nurse on 03/31/25. The skin check documented the following: Pressure to sacrum, right heel. Abrasion to right and left outer forearm. Surgical non-removable dressing to front right hip. Healed surgical incision to chest, bilateral inner thighs. Ostomy to left lower quadrant. A progress note was generated on 03/31/25 at 1:13 PM pursuant to the skin check. The note was identified as a late entry for 03/28/25 at 7:33 PM. The note identified the skin issues identified in the skin check described above. The note also stated the wound nurse was notified. On 03/31/25 at 12:42 PM, a skin and wound evaluation was performed for a deep tissue pressure injury to the right heel present on admission. The pressure injury was measured as 8.2 cm [centimeters] in length by 3.3 cm in width by 0.1 cm in depth. There was no evidence of infection, exudate (drainage), induration, or edema. The pressure injury was described as pink or red and discolored. The edges of the pressure injury were attached. Surrounding tissue was denuded, discolored black or blue, dry/flaky, and fragile. On 03/31/25 at 12:46 PM, a skin and wound evaluation was also performed for a deep tissue pressure injury to the sacrum present on admission. No measurements were recorded. There was no evidence of infection, exudate (drainage), induration, or edema. The pressure injury was described as discolored. The edges of the pressure injury were attached. Surrounding tissue was fragile. Treatment for the right heel deep tissue injury pressure ulcer was ordered on 03/31/25. The order stated, right heel (pressure) - cleanse with hydrating foam cleanser, pat dry and apply sure prep, leave OTA [open to air] every day and night shift for pressure. Treatment for the sacral deep tissue pressure ulcer was also ordered on 03/31/25. The order stated, Sacrum (pressure) - cleanse with hydrating foam cleanser, apply zinc oxide paste, every day and night shift for pressure. Measurements of the right heel deep tissue injury were recorded on a skin and wound evaluation performed on 04/07/25. The right heel pressure injury measured 1.5 cm in length and 1.0 cm in width. The Director of Nursing (DON) was interviewed on 09/29/25 at 11:50 AM. She acknowledged Resident #164's deep tissue pressure injuries had not been fully assessed upon admission. She also acknowledged treatment for these pressure injuries had not been initiated upon admission. The DON stated it was the facility's standard of care to assess and initiate treatment for pressure ulcer injuries upon admission. No further information was provided through the completion of the survey process.

Based on record review and staff interview, the facility failed to accurately document the administration and refusal of medications. The facility also failed to ensure residents had current orders for medication given. These were random opportunities for discovery. Resident Identifiers: #51 and #34. Facility census: 157. Findings included:a) Resident #34 Review of Resident #34's physician's orders showed an order written on 07/25/25 for gabapentin 100 mg two (2) times a day for neuropathy. Both the Medication Administration Record (MAR) and the Controlled Drug Record - Individual Patient's Narcotic Record were reviewed for July 2025. The following discrepancy was found: On 07/28/25, the MAR documented the resident received the scheduled gabapentin dose at 9:00 AM. However, the Controlled Drug Record did not document removal of gabapentin from the resident's supply. The resident was noted to occasionally refuse gabapentin. On 09/30/25 at 2:30 PM, Clinical Registered Nurse (RN) #206 stated she could not explain why the MAR documented the gabapentin was given but the Controlled Drug Record did not document a dose was removed. She stated the MAR might be in error and the resident might have refused gabapentin on 07/28/25 at 9:00 AM. No further information was provided through the completion of the survey process. b) Resident #51Review of Resident #51's physician's orders showed an order written on 08/13/25 for gabapentin 100 mg two (2) times a day for neuropathy for eight (8) days. The medication was started on 08/14/25 and was completed after eight (8) days on 08/21/25. Both the Medication Administration Record (MAR) and the Controlled Drug Record - Individual Patient's Narcotic Record were reviewed for August 2025. The following discrepancies were found:On 08/14/25 at 9:00 AM, the Controlled Drug Record documented a gabapentin capsule had been removed from the resident's supply. However, gabapentin was not documented as given on the MAR. The area on the MAR to indicate the medication had been given was blank. On 08/15/25 at 9:00 AM, the Controlled Drug Record documented a gabapentin capsule had been removed from the resident's supply. However, gabapentin was not documented as given on the MAR. The area on the MAR to indicate the medication had been given was blank. On 08/18/25 at 9:00 AM, the Controlled Drug Record documented a gabapentin capsule had been removed from the resident's supply. However, gabapentin was not documented as given on the MAR. The area on the MAR to indicate the medication had been given was blank. On 08/18/25 at 9:00 PM, the Controlled Drug Record documented a gabapentin capsule had been removed from the resident's supply. However, gabapentin was not documented as given on the MAR. The area on the MAR to indicate the medication had been given was blank. Following 08/21/25, when the eight (8) days of prescribed medication was completed, the medication continued to be signed out as removed on the Controlled Drug Record on the following dates: 08/22/25 at 9:00 AM and 9:00 PM08/23/25 at 9:00 AM08/24/25 at 9:00 AMThe MAR was marked with an X for these dates and times because the medication was not ordered for these dates. Gabapentin was reordered for the resident on 08/25/25. On 09/30/25 at 2:30 PM, Clinical Registered Nurse (RN) #206 confirmed gabapentin had not been documented as given on the MAR despite being signed out as removed on the Controlled Drug Record on 08/14/25, 08/15/25, and 08/18/25. She also confirmed gabapentin had been signed out as removed on the Controlled Drug Record on 08/22/25, 08/23/25, and 08/24/25, despite the resident not having an order for the medication on these dates.

Based upon record review and staff interview, the facility failed to complete a drug regimen review at least once a month by a licensed pharmacist, and the facility's medical director failed to act upon irregularities reported by the pharmacist. This was found to be true for three (3) of five (5) residents reviewed during the long-term care survey process. Resident identifiers: #1,#10, #100. Facility census: 157. Findings included: a) Policy Review A review of the facility's Medication and Regimen Review and Reporting policy revealed the following statement, The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly. The nursing care center follows up on the recommendations to verify the appropriate action has been taken. Recommendations should be acted upon within 30 calendar days or per facility specific protocols. For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale of why the recommendation is rejected in the resident's medical record.b) Resident #100 A review of the medical record documents Resident #100 has the following psychosocial diagnoses: The Resident had the following psychotropic medication orders: Xanax Oral Tablet 1 MG (Alprazolam)Give 1 mg by mouth three times a day for anxiety disorderPharmacy Active: 09/09/25 Quetiapine Fumarate ER Oral Tablet Extended Release 24 Hour 150 MG Give 1 tablet by mouth at bedtime for bipolar disorder with psychosisPharmacy Active: 09/09/25 Citalopram Hydrobromide Tablet 10 MGGive 3 tablet by mouth one time a day for depression (Brand name Celexa) Give 30 mg PO daily. Pharmacy Active: 08/06/25 Wellbutrin XL Oral Tablet Extended Release 24 Hour 150 MG (Bupropion HCl)Give 1 tablet by mouth one time a day for depression AEB refusing care and cryingPharmacy Active: 03/30/25 lamotrigine Oral Tablet 100 MG Give 100 mg by mouth two times a day for bipolar disorder mood changes and cryingPharmacy Active: 03/29/25 A review of the monthly pharmacist medical regimen reviews (MRR) for the calendar year 2025 in the medical record revealed there was no consultant pharmacist MRR for the month of April 2025. The surveyor asked the DON on 09/24/25 around 9:30 AM if there had been one conducted, and she replied that she would check. Later that afternoon, the DON stated she was unable to locate a MRR for April 2025. Further review of the medical record, there was a recommendation from the consultant pharmacist dated 08/01/25 on his MRR, reminding the physician of the need for a gradual dose reduction review of psychotropic medications. The Medical Director did not review, did not sign, or did not acknowledge recommendation. c) Resident #10A review of the medical record documents Resident #1 has the following psychosocial diagnoses:The Resident was prescribed these medications:Divalproex Sodium Oral Tablet Delayed Release 250 MGGive 1 tablet by mouth two times a day for bipolar disorderPharmacy Active: 09/08/25bupropion HCl ER (SR) Oral Tablet Extended Release 12 Hour 150 MG Give 2 tablet by mouth one time a day for MDD Increased to 300 mg PO by in-house psychiatry Pharmacy Active: 09/09/25Venlafaxine HCL ER 150 MG CAPGive 1 capsule by mouth one time a day for behaviorsPharmacy Active: 07/15/25Buspirone HCl Tablet 5 MGGive 1.5 tablet by mouth two times a day for anxietyPharmacy Active: 07/15/25 Seroquel Oral Tablet 100 MG (Quetiapine Fumarate)Give 1 tablet by mouth at bedtime for schizoaffective disorderPharmacy Active: 06/17/25A review of the medical record for the consultant pharmacist medication regimen reviews (MRR), shows the pharmacist consistently reviewed medications monthly. However, there was an irregularity report completed on 08/01/25, which stated According to CMS guidance under F605 (Chemical Restraints), For any resident who is receiving a psychotropic medication, the facility must show evidence that a gradual dose reduction has been attempted unless clinically contraindicated. Please consider a trial dose reduction on one of these medications. Medications were listed as Citalopram Hydrobromide Oral Tab 40 MG, Iamotrigine Oral Tablet 100 MG, Seroquel Oral Tab 50 MG, Wellbutrin XL Oral Tablet 150 MG, and Xanax Oral Tablet 1 MG.This recommendation was never reviewed, acknowledged, or any action taken by the Medical Director in accordance with the facility policy.The surveyor reviewed this finding with the DON on 09/24/25, and she was asked if there was any additional information she could provide related to the 08/01/25 MRR recommendation for GDR. A progress note was then provided by the DON dated 09/03/25 by Nurse Practitioner (NP) #302 whereby a GDR review was not recommended at the present time due to the resident experiencing symptoms of significant distress, as evidenced by PTSD, anxiety and hallucinations. NP did prescribe a change to Seroquel Oral Tablet 100 MG (Quetiapine Fumarate) to Seroquel XR 150 MG, which was an increase to resident's psychotropic medication.d) Resident #1A review of resident #1's medical record for medication regimen reviews (MRR) included a new admission review by the consultant pharmacist dated 07/05/25. In this MRR, the pharmacist requested clarification for the current order for Bupropion SR 150 MG for antidepressant. Pharmacist recommendation was Please clarify indication for use. The medical director did not acknowledge, review or act upon this recommendation.This was reviewed with the DON on the afternoon of 09/09/25. The DON was asked if she had any additional information to provide on the MRR. The DON had nothing to add.

Based on observation, record review, and staff interview, the facility failed to store medications within accepted standards of care. A multi-use vial of tubersol injection had been in use over 30 days. These was a random opportunity for discovery. Facility census: 157. Findings included: a) Multi-use vial of Tubersol On 09/23/2025 at 10:48 AM, the medication storage room in the Transitional Care Unit was inspected with the Director of Nursing (DON) in attendance. A multi-use vial of Tubersol (tuberculin purified protein derivative, or PPD) located in the refrigerator was noted to have an opening date of 08/19/25. The box stated to discard 30 days after opening. Tubersol is used in a skin test to help diagnose tuberculosis (TB) infection. The DON acknowledged the Tubersol multi-use vial should have been discarded 30 days after opening. The Tubersol package insert, available on-line of the Food and Drug Administration Website, stated, A vial of Tubersol which has been entered and in use for 30 days should be discarded.No further information was provided through the completion of the survey process.

Based upon Observation and Staff interviews the facility failed to ensure that dishware and serving items are kept in clean and sanitary area once cleaned. They were stored in the hallway to finish drying, allowing for possible recontamination. The hallway was in a main intersection of the first floor and had lots of foot traffic and people moving through it. This was a random opportunity for discovery that has the potential to effect more then one resident. Facility census: 157. On 09/29/25 at 9:03 PM an observation revealed dishes, cups, tray tops and glasses left out in hallway (main hall outside dining area). The dishes were exposed to possible recontamination. This hallway is in the main intersection on the first floor and has lots of foot traffic and items passing through it daily. The area is also under a vent that can allow dust to fall upon the clean dishes.During an interview with Kitchen Staff (KS) #3 on 09/29/25 at 9:05 PM KS#3 stated that they wash them and sanitize them, but because the room is so small they need to leave them in the hallway to dry. Then they put them away for use later. KS #3 said, We never thought about them getting dirty from being out there.

Based upon Observation and Staff interviews the facility failed to ensure use of proper infection control practices to prevent the potential spread of disease through improper/non use of PPE while in a Enhanced Barrier Protection room. This was observed on more than one occasion. Resident identifiers: #80, #9 and #14. Census: 157. a) Resident #80 During med pass LPN #38 did not use PPE while giving resident #80 her medications. Resident is currently on enhanced barrier precautions (EBP) and the sign is present on door with marking for who it applies to. The LPN did sanitize hands, but did not apply PPE per policy. She had direct contact with resident, LPN adjusted resident in bed as well as hugged resident before leaving room. When asked what they do if a room is marked with EBP sign LPN #189 stated that if they will have direct patient contact they need to put on PPE, gloves gown, mask ect . b) Resident #9On 09/24/25 8:45 AM a nurse and an aide were in in room [ROOM NUMBER]-A doing morning Activities of Daily Living (ADLs) and clearing up Resident #9 without using proper PPE. No gown, gloves or masks observed. Both residents in room [ROOM NUMBER] beds A Resident #9 and B Resident #14 were on EBP precautions. Resident #9 was on EBP due to having a chest port for dialysis. Resident #14 was on EBP due to abnormal blood chemistry, An observation revealed a sign on the door of room [ROOM NUMBER] with room and beds effected listed. A PPE cart was observed outside room [ROOM NUMBER] and was stocked with appropriate PPE needed Administrator #200 was asked who the two nurses were in the room with Resident #9. Administrator #200 stated that it was Nurse #165 and the Wound care Licensed Practical Nurse (LPN) #195. Administrator #200 said they should have both been in proper PPE per policy when in direct contact with a resident.

Based upon record review and staff interview, the facility failed to inform the resident or resident's representative in advance, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. This was found to be true for two (2) of five (5) residents reviewed for psychotropic medication use during the long-term care survey process. Resident identifiers: # 1, #10. Facility census: 157. Findings included:a) Resident #10The resident had the following pharmacy orders: Xanax Oral Tablet 1 MG (Alprazolam) Give 1 mg by mouth three times a day for Anxiety Disorder Pharmacy Active 9/9/2025 Quetiapine Fumarate ER Oral Tablet Extended Release 24 Hour 150 MG (Quetiapine Fumarate) (Brand name Seroquel)Give 1 tablet by mouth at bedtime for bipolar disorder with psychosisPharmacy Active: 09/09/25 Citalopram Hydrobromide Tablet 10 MG (brand name Celexa)Give 3 tablet by mouth one time a day for depression Give 30 mg PO daily. Pharmacy Active: 08/06/25 Upon review of the medical record, informed consents for the use of Xanax, Celexa, and Seroquel were not located. The Surveyor requested to see informed consents on 09/24/25 at approximately 11:37 AM from RN Clinical Lead #206. Around 2:10 PM, the informed consents had not been provided and these were requested again. Approximately thirty minutes later, the DON presented an informed consent for Xanax, Celexa, and Seroquel. The informed consent was dated 09/24/25, which documented the resident or resident's representative had not been informed in advance of receiving these drugs of the risks and benefits, or provided other treatment options. The DON stated the facility had apparently missed getting the consent.b) Resident #1A review of Resident #1's medical record documents the following pertinent diagnoses: Resident #1 had the following pharmacy orders: Bupropion HCl ER (SR) Oral Tablet Extended Release 12 Hour 150 MG. Give 2 tablet by mouth one time a day for MDD Increased to 300 mg PO by in-house psychiatry. Pharmacy Active 9/9/2025 Buspirone HCl Tablet 5 MG Give 1.5 tablet by mouth two times a day for anxietyPharmacy Active 7/15/2025 Upon review of the medical record, the surveyor was unable to find informed consents for the use of Wellbutrin or Buspar. The surveyor asked the facility to provide an informed consent for these two medications on 09/25/25 at 9:18 AM. At approximately 2:10 PM on 09/25/25, when surveyor asked again about the informed consents, the DON stated the facility failed to initiate the informed consents and stated, We will get this completed immediately.

Based on record review and staff interview, the facility failed to provide a Notice of Transfer/Discharge, and a written Bed Hold notice to a resident and/or the resident's legal representative when the resident was transferred to the hospital. This was true for one (1) of nine (9) residents reviewed for hospitalizations. Resident identifier: #177. Facility census. 157.Findings included: a) Resident #177 A record review, completed on 09/29/25 at 6:30 PM, revealed the following information: Resident #177 was sent out to the hospital on [DATE] at 2:06 PM. There was no evidence in the electronic medical record the facility had notified the resident or the resident's representative of the transfer/discharge and the reasons for the transfer in writing. Additionally, there was no evidence the facility provided a written notice which specified the duration of the bed-hold, if any, during which the resident would be permitted to return to the nursing home. During an interview, on 09/20/25 at approximately 12:45 PM, Regulatory Compliance Officer (RCO) #157 confirmed the facility was unable to produce evidence that a Notice of Transfer/Discharge and a Bed Hold Notice had been given for Resident #177's discharge to the hospital on [DATE].

Based upon record review and staff interview, the facility failed to develop a person-centered comprehensive care plan, and implement the plan to meet the resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. This was found to be true for three (2) of thirty-four (34) residents reviewed during the long-term care survey process. Resident identifiers: #8, #100. Facility census: 157. Findings included: A) Resident #8 A personalized care plan was developed for this resident, but was not carried out. The Care Plan included a focus area pertaining to a risk for skin breakdown due to the resident's decreased activity, frail fragile skin, impaired cognitive function, impaired mobility. One intervention was to turn and position the resident every 2-3 hours. This intervention was developed on 05/15/24, and revised on 02/19/25. Among the resident's diagnoses were a facility-acquired Stage 3 pressure ulcer of other site diagnosed on [DATE], and a non-pressure chronic ulcer of other part of right foot, diagnosed on [DATE] also acquired during stay. The medical record was reviewed to see if the care plan intervention for turning and positioning was being carried out. According to the medical record, turning and positioning were only completed on one (1) shift on the following dates:07/01/25, 07/03/25, 07/06/25, 07/08/25, 07/09/25, 07/10/25, 07/11/25, 07/14/25, 07/15/25, 07/18/25, 07/20/25, 07/19/25, 07/23/25, 07/25/25, 07/26/25, 07/27/25, 08/02/25, 08/07/25, 08/12/25, 08/16/25, 08/27/25, 09/08/25, and 9/29/25. Turning and positioning were not completed on any shift on the following dates:07/05/25, 07/13/25 The turning and positioning documentation and care plan were reviewed with the DON on 09/30/2025 at approximately10:00 AM. The DON acknowledged there was no documentation for turning and positioning for the above shifts, and turning and positioning had only been documented on one shift on the other dates listed above, thus not carrying out the personalized care plan for the resident. B) Resident #100 Resident #100 has impairment on left side of upper and lower extremities On 09/15/25, resident was diagnosed with bilateral Stage 2 pressure ulcers to both buttocks. The Resident is dependent upon staff for dressing, toileting, bathing, personal hygiene, and requires set up assistance for eating. The medical record also documents the following pertinent diagnoses related to range of motion: CONTRACTURE, LEFT WRIST Non-Surgical Orthopedic/Musculoskeletal 1/5/2022 During StayCONTRACTURE, LEFT ELBOW Non-Surgical Orthopedic/Musculoskeletal 1/5/2022 During StayCONTRACTURE, LEFT HAND Non-Surgical Orthopedic/Musculoskeletal 6/11/2018 Admission/Readmission The resident's orders for improvement of range of motion included: Physical Therapy (PT)- Evaluation & treatment as recommended No directions specified for order Other Active 2/26/2025Resident to wear left palm protector or wash cloth when splint is off as tolerated; may be removed for skin checks and hygiene licensed nurse to remove and assess skin integrity every shiftevery day and night shiftOther Active 6/10/2024Occupational Therapy to evaluate and treat as needed.No directions specified for order.Other Active 6/14/2022A personalized care plan was developed for the resident. One focus area was the prevention of skin breakdown. Interventions included:Assist resident to turn and reposition every 1 - 2 hours while in bed and/or chair with up to maximum assist. Date initiated 04/10/23Assist resident in turning and repositioning every 2 - 3 hours. Date initiated 05/08/24Documentation for turning and positioning of he resident were requested for the months of July, August, and September of 2025, as a sample for determining if the care plan was being carried out. On the the following dates, turning and positioning were only completed on one shift:07/02/25, 07/07/25, 07/09/25, 07/10/25, 07/11/25, 07/13/25, 07/15/25, 07/19/25, 07/21/25, 07/26/25, 08/18/25, 09/11/25

Based on record review and staff interview, the facility failed to obtain lab services in a timely fashion for a resident. This was true for one (1) of five (5) residents reviewed for unnecessary medications throughout the Long-Term Care Survey Process. Resident identifier: #6. Facility census:157.Findings included: a) Resident #6 During a record review, completed on 09/29/2025 at 9:15 AM, there was no evidence in Resident #6's electronic medical record that blood work had been completed in the month of July 2025 as per a physician's order. The Director of Nursing (DON) was interviewed on 09/29/2025 at 12:00 PM. The DON confirmed there had been an active physician order stating, HGA1C (a blood test that provides an average of your blood sugar levels), CMP (Comprehensive Metabolic Panel) and CBC (Complete Blood Count) every 4 months - March, July, November. The DON reported the facility was unable to produce evidence that the lab work had been completed as ordered.

Based on record review and staff interview the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that were accurately documented. This was a random opportunity for discovery. Resident #6. Facility census: 157.Findings included: a) Resident #6 A medical record review, completed on 09/29/2025 at 9:15 AM, revealed the following details: - Resident #6 transferred to room [ROOM NUMBER]-B on 04/09/25.- On 04/20/25 there was an Encounter Note which incorrectly documented Resident #6 was in room [ROOM NUMBER]. - On 05/15/25 there was an Encounter Note which incorrectly documented Resident #6 was in room [ROOM NUMBER].- On 05/17/25 there was an Encounter Note which incorrectly documented Resident 36 was in room [ROOM NUMBER]. - Resident #6 transferred to room [ROOM NUMBER]-B on 06/26/25.- On 08/14/25 there was an Encounter Note which incorrectly documented Resident #6 was in room [ROOM NUMBER].- On 08/16/25 there was an Encounter Note which incorrectly documented Resident #6 was in room [ROOM NUMBER].- On 08/16/25 there was a second Encounter Note which incorrectly documented Resident #6 was in room [ROOM NUMBER]. During an interview with the Director of Nursing on 09/29/25 at 12:05 PM, she acknowledged the aforementioned encounter notes had listed the incorrect room number for Resident #6.

Based on record review and staff interview, the facility failed to provide pneumococcal vaccinations in accordance with professional standards of practice. This deficient practice had to potential to affect one (1) of five (5) residents reviewed for the care area of vaccinations. Resident Identifier: #34. Facility Census: 157. a) Resident #34 The facility's policy titled Pneumococcal Vaccination with effective date 05/04/15 and revision date 09/15/25 stated pneumococcal vaccinations in adherence with current recommendations of the Advisory Committee on Immunizations Practices (ACIP) as set forth by the Centers for Disease Control and Prevention. The CDC publication titled Pneumococcal Vaccine Timing for Adults dated March 2025, which is available on-line, stated adults 50 years or older who have only received the pneumococcal conjugate vaccine (PCV) 13 should receive a single dose of PCV 21 or PCV 20 at least one year after the PCV 13 dose. Resident #34 was over [AGE] years old. Review of Resident #34's medical records showed a pneumococcal vaccine informed consent signed by the resident and dated 06/01/25. The option I hereby give the Center permission to administer the (list type) pneumococcal vaccine, based upon my vaccination history, vaccine guidelines, and/or my physician's recommendations. After list type, there was a blank line to list the type of pneumococcal vaccine to be given. The words Up to date - does not need were handwritten in the line after list type. Resident #34's vaccination record in the electronic health records, showed the resident had recieved pneumococcal conjugate vaccination (PCV) 13 on 03/18/16. No further pneumococcal vaccines were documented. On 09/24/25 at 8:26 AM, the Infection Preventionist confirmed Resident #34 was not fully vaccinated for pneumococcal disease. She agreed the resident should have been offered a Prevnar 20 injection. The Infection Preventionist stated she offered Resident #34 a Prevnar 20 injection that morning after surveyor intervention. The resident refused the vaccination. No further information was provided through the completion of the survey process.

Based on observation, medical record review and staff interview the facility failed to ensure the procedures they had in place for verifying a resident's choices Cardiopulmonary Resuscitation (CPR) were able to communicated as soon as possible so that staff know immediately what action to take or not when an emergency arises. The facility used the POST form to document and verify the resident's choices regarding cardiopulmonary resuscitation. The facility failed to ensure the POST form was kept on the medical record in the event of an emergency. This process had the potential to affect all residents in the facility. Facility census: 149. The process of not ensuring POST forms were kept on the medical record in the event of an emergency created an immediate jeopardy situation. The facility was informed of this immediate jeopardy situation on [DATE] at 6:06 PM. The facility responded with a plan of correction on [DATE] at 6:52 PM. Findings included: a) Resident #150 Medical Record Review (MRR) revealed that on [DATE] a nurse contacted Resident #150's daughter at 12:31 PM and notified her that the facility staff had performed CPR on her father and that the resident was sent to the emergency department (ED). The nurse informed the daughter that after the incident a chart review revealed the resident had a POST form that reflected the resident was a DNR (do not resuscitate). The facility provided an unusual occurrence related to Resident #150 The report stated On [DATE] Resident #150 was observed absent of vital signs and non-responsive. Staff attempted to rouse the resident, but were unsuccessful. The nurse told the CNA to go to the desk and check the resident's chart for code status. CNA looked at the report sheet (written report received from hospital prior to resident's admission) in the front of the chart, returned to room, and told the nurse the resident was a full code. CPR was initiated, a code blue was called, 911 was contacted. Nurses from other units responded to code and arrived on the unit. EMS arrived and took over life-saving measures. Attempted to contact the resident's family to advise of the situation, but were unable to contact. Later received a return call from the family and were notified of the situation. While charting about the incident later in the shift, the nurse noted that resident's POST form indicated that resident's code status was DNR, selective treatments, no feeding tube. Investigation was initiated. APS, Ombudsman, and OHFLAC were notified. The report went on to describe On [DATE], the resident was sitting on the toilet attempting to have a bowel movement. The CNA assigned to the resident entered the resident's restroom to inquire about the resident's needs. Resident stated he would like a cup of ice water. CNA exited the room to obtain ice water and returned to the room, approximately six minutes later. Upon return to the room, the resident was still sitting on the toilet, but CNA noted that the resident was unresponsive. The CNA called for assistance. The nurse entered the room and evaluated the resident and attempted to rouse. Nurse sent CNA to the nurse's station to look in the resident's chart for code status. CNA looked at the report sheet from the hospital and returned to the room stating that resident was a full code. A code blue was called. CPR was initiated, 911 was contacted. Nurses from other units arrived to help in response to the code. EMS arrived a few minutes later and took over life saving measures. Resident was transported to the hospital. Nurse attempted to contact the resident's family to advise them of the situation. Later in the shift, while charting about the event, the nurse noted that the POST form in the resident's chart had been changed on [DATE] to DNR, selective treatments and no feeding tube, signed by resident. The facility responded to this event by doing verbal and written re-education regarding the CPR process and checking advanced directives were completed with the nurse. On [DATE], re-education was initiated with all licensed nurses regarding the process for checking residents' advanced directives and the process for CPR. A review of the education provided by the facility in July revealed the following information was presented to staff: Upon discovery of a resident in cardiopulmonary arrest (no apparent pulse, blood pressure or respiration), staff will do the following: Call for Assistance Alert the licensed nurse on unit if not already done and CPR certified staff in building (overhead page by hitting *98, code blue can be called at this time to alert additional staff) Prepare the patient for CPR while determining the presence of a Do Not Resuscitate (DNR) order - this will be located on the POST form AND/OR in PCC. If there is NO presence of DNR order or DNR status in the medical record, the staff will initiate CPR at that time. If a CNA is needed to retrieve the chart due to licensed nurse in resident's room, please ask that the CNA bring the chart to the nurse to confirm code status. Licensed Practical Nurse #46 completed the education but wrote a note at the bottom of the education sheet stating, I understand the policy and process of CPR. The issue was with the paper in the front saying full code and the POST being a few back and having a different code status. On [DATE] at 3:00 PM On [DATE] at 4:30 PM the surveyor reviewed the medical record for Resident #138, #1, #8. None of these residents had a POST form on their chart. Staff Member #406 said the forms had been pulled from the chart but she would get them put back on. The surveyor interviewed Licensed Practical Nurse #402 who said they would check the resident's POST form if she needed to know a resident's code status in an emergency. Staff Member #406 had a stack of the POST forms and she asked the surveyors whose POST she was looking for. Staff Member #106 said she would put them back on the medical records. On [DATE] at 4:40 PM the surveyor interviewed Licensed Practical Nurse #404 who also said they would check the POSTS form for code status in an emergency. On [DATE] at 4:50 PM Licensed Practical Nurse #405 also said she would check the POST form for code status or call the charge nurse. The assistant administrator was interviewed on the memory care unit on [DATE] at 5:01 PM. She had POST forms in her hand that had been pulled from the charts. She said there were 15 POST forms and that she had pulled them to do an audit. The pulling of POST forms from the charts and licensed nursing staff stating that is where they would go to check code status and perform CPR if no POST was present created an immediate jeopardy situation. The facility was informed of this immediate jeopardy on [DATE] at 6:06 PM. The facility provided an acceptable plan of correction at 6:52 PM on [DATE]. The plan of correction included the following: The process for confirming code status - education - Once you find a resident who is unresponsive, without respiration or vitals, check for pulse, check for respirations, if neither are present please check for POST form first on the chart prior to initiating CPR. -If for any reason a POST form is not present please check PCC (point click care) for a code status -This is located on the EMAR (electronic medication administration record), click on the patent, it will show the order and patient. -This is also located on the individual resident dashboard. When you click on the patient name, it shows code status in the area below the picture. No matter what tab you click on the code status remains visual on the screen. -If anyone removes a POST form for any reason, they must confirm there is an order in PCC for their code status preference before taking the form to copy, scan, have signed or for any reason reason. The Immediate Jeopardy was abated on [DATE] at 11:00 am after education was confirmed and staff displayed understanding of the education they received.

The facility failed to ensure the quality assessment and assurance committee failed to identify quality deficiencies. In [DATE] Resident #150 was given cardiopulmonary resuscitation when his advanced directive indicated he wished to not be resuscitated. The facility quality assessment and assurance (QAA) committee addressed the issue of staff not identifying a resident's correct code status from [DATE] until [DATE]. After stopping the QAA code checks the facility developed another code status issue. Staff members were taking POST forms off the medical records for audits. The nursing staff stated the POST forms are where they would check for a resident's code status in an emergency. This practice had the potential to affect more than a limited number of residents. Facility census: 149. Findings included: a) Resident #150 Medical Record Review (MRR) revealed that on [DATE] a nurse contacted Resident #150's daughter at 12:31 PM and notified her that the facility staff had performed CPR on her father and that the resident was sent to the emergency department (ED). The nurse informed the daughter that after the incident a chart review revealed the resident had a POST form that reflected the resident was a DNR (do not resuscitate). The facility provided an unusual occurrence related to Resident #150 The report stated On [DATE] Resident #150 was observed absent of vital signs and non-responsive. Staff attempted to rouse the resident, but were unsuccessful. The nurse told the CNA to go to the desk and check the resident's chart for code status. CNA looked at the report sheet (written report received from hospital prior to resident's admission) in the front of the chart, returned to room, and told the nurse the resident was a full code. CPR was initiated, a code blue was called, 911 was contacted. Nurses from other units responded to code and arrived on the unit. EMS arrived and took over life-saving measures. Attempted to contact the resident's family to advise of the situation, but were unable to contact. Later received a return call from the family and were notified of the situation. While charting about the incident later in the shift, the nurse noted that resident's POST form indicated that resident's code status was DNR, selective treatments, no feeding tube. Investigation was initiated. APS, Ombudsman, and OHFLAC were notified. The report went on to describe On [DATE], the resident was sitting on the toilet attempting to have a bowel movement. The CNA assigned to the resident entered the resident's restroom to inquire about the resident's needs. Resident stated he would like a cup of ice water. CNA exited the room to obtain ice water and returned to the room, approximately six minutes later. Upon return to the room, the resident was still sitting on the toilet, but CNA noted that the resident was unresponsive. The CNA called for assistance. The nurse entered the room and evaluated the resident and attempted to rouse. Nurse sent CNA to the nurse's station to look in the resident's chart for code status. CNA looked at the report sheet from the hospital and returned to the room stating that resident was a full code. A code blue was called. CPR was initiated, 911 was contacted. Nurses from other units arrived to help in response to the code. EMS arrived a few minutes later and took over life saving measures. Resident was transported to the hospital. Nurse attempted to contact the resident's family to advise them of the situation. Later in the shift, while charting about the event, the nurse noted that the POST form in the resident's chart had been changed on [DATE] to DNR, selective treatments and no feeding tube, signed by resident. The facility responded to this event by doing verbal and written re-education regarding the CPR process and checking advanced directives were completed with the nurse. On [DATE], re-education was initiated with all licensed nurses regarding the process for checking residents' advanced directives and the process for CPR. A review of the education provided by the facility in July revealed the following information was presented to staff: Upon discovery of a resident in cardiopulmonary arrest (no apparent pulse, blood pressure or respiration), staff will do the following: Call for Assistance Alert the licensed nurse on unit if not already done and CPR certified staff in building (overhead page by hitting *98, code blue can be called at this time to alert additional staff) Prepare the patient for CPR while determining the presence of a Do Not Resuscitate (DNR) order - this will be located on the POST form AND/OR in PCC. If there is NO presence of DNR order or DNR status in the medical record, the staff will initiate CPR at that time. If a CNA is needed to retrieve the chart due to licensed nurse in resident's room, please ask that the CNA bring the chart to the nurse to confirm code status. Licensed Practical Nurse #46 completed the education but wrote a note at the bottom of the education sheet stating, I understand the policy and process of CPR. The issue was with the paper in the front saying full code and the POST being a few back and having a different code status. On [DATE] at 3:00 PM On [DATE] at 4:30 PM the surveyor reviewed the medical record for Resident #138, #1, #8. None of these residents had a POST form on their chart. Staff Member #406 said the forms had been pulled from the chart but she would get them put back on. The surveyor interviewed Licensed Practical Nurse #402 who said they would check the resident's POST form if she needed to know a resident's code status in an emergency. Staff Member #406 had a stack of the POST forms and she asked the surveyors whose POST she was looking for. Staff Member #106 said she would put them back on the medical records. On [DATE] at 4:40 PM the surveyor interviewed Licensed Practical Nurse #404 who also said they would check the POSTS form for code status in an emergency. On [DATE] at 4:50 PM Licensed Practical Nurse #405 also said she would check the POST form for code status or call the charge nurse. The assistant administrator was interviewed on the memory care unit on [DATE] at 5:01 PM. She had POST forms in her hand that had been pulled from the charts. She said there were 15 POST forms and that she had pulled them to do an audit. The pulling of POST forms from the charts and licensed nursing staff stating that is where they would go to check code status and perform CPR if no POST was present created an immediate jeopardy situation. The facility was informed of this immediate jeopardy on [DATE] at 6:06 PM. The facility provided an acceptable plan of correction at 6:52 PM on [DATE]. The plan of correction included the following: The process for confirming code status - education - Once you find a resident who is unresponsive, without respiration or vitals, check for pulse, check for respirations, if neither are present please check for POST form first on the chart prior to initiating CPR. -If for any reason a POST form is not present please check PCC (point click care) for a code status -This is located on the EMAR (electronic medication administration record), click on the patent, it will show the order and patient. -This is also located on the individual resident dashboard. When you click on the patient name, it shows code status in the area below the picture. No matter what tab you click on the code status remains visual on the screen. -If anyone removes a POST form for any reason, they must confirm there is an order in PCC for their code status preference before taking the form to copy, scan, have signed or for any reason reason. The Immediate Jeopardy was abated on [DATE] at 11:00 am after education was confirmed and staff displayed understanding of the education they received.

Based on resident interview, family interview, record review, and staff interview, the facility failed to protect residents from sexual abuse. Resident #208 had a previous history of sexual behaviors toward other residents. The facility failed to protect Resident #15 from unwanted sexual touching by Resident #208. Although Resident #208 had been transferred to another facility by the time of the survey, the State Agency determined the facility's processes that failed to protect Resident #15 placed all residents in the facility in an immediate jeopardy situation. The State Agency notified the Nursing Home Administrator of the immediate jeopardy situation on 03/25/24 at 4:27 PM. The facility submitted a plan of correction (POC) on 03/25/24 at 7:19 PM. The State Agency requested revisions and an additional POC was submitted on 03/25/24 at 8:08 PM. The State Agency requested additional revisions and the final POC was submitted and approved on 03/25/24 at 8:16 PM. The State Agency verified the POC was implemented by reviewing the facility's resident interviews and resident evaluations. The State Agency also reviewed the facility's training records and interviewed staff members. The immediate jeopardy was abated on 03/26/24 at 1:45 PM. Resident #15 was harmed by the sexual abuse. She reported sadness and depression. She also had to undergo evaluation for physical injury at the emergency room . Findings included: a) Resident #15 During an interview, on 03/18/24 at 12:12 PM, Resident #15 stated a man had come into her room and touched my breast and crotch. She stated her tube feeding tubing had become disconnected from her gastrostomy tube and tube feeding leaked all over. She stated she started yelling and ringing her call light, but staff were slow to respond because they were busy. She stated the resident then went over to her roommate's side of the room, and her roommate began cursing at him. Resident #15 stated staff eventually came in and removed the perpetrator. She believed the perpetrator was arrested and never returned to the facility. On 03/19/24 at 4:00 PM, Resident #15's representative was interviewed on the telephone. She stated Resident #15 had been traumatized by the incident. She also believed the emergency room evaluation caused further distress for the resident. During a follow-up interview on 03/25/24 at 9:15 AM, Resident #15 stated the perpetrator initially touched her over the blanket, but then touched her under the blanket and then under her clothing. The resident stated the perpetrator touched her on the outside of her private area. She did not report digital penetration. She stated she tried not to think about the incident. She stated she felt sad and depressed when she thought about it. She stated that for a while she was nervous whenever she heard footsteps in the hallway. Resident #15 stated she liked to keep the television on at all times, so she didn't hear any footsteps. She also stated watching television kept her from thinking about the incident. Review of Resident #15's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 01/16/24 showed the resident had a brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The resident had a diagnosis of dementia. Resident #15 was determined by her physician to lack capacity to make medical decisions. A family member was her Medical Power of Attorney [MPOA]. The facility's reported incidents were reviewed. The following reportable was made on 02/02/24, Resident to Resident with potential inappropriate touching. Alleged perpetrator (resident) placed on one on one supervision and investigation initiated. On 02/07/24, the facility requested additional time for investigation. The five (5) day follow-up stated as follows: On 2/2/2024, the alleged a [sic] resident to resident with a potential of inappropriate touching. This was a resident to resident incident. The perpetrator, [Resident #208] was immediately placed on a 1:1 supervision. APS [Adult Protective Service], Ombudsman, OHFLAC [Office of Health Facility Licensure and Certification], and [City] Police were notified and investigation was initiated. [Resident #15] is a long-term resident who was admitted on [DATE]. [Resident #15]'s diagnoses include epilepsy, dementia, unspecified protein-calorie malnutrition, and chronic osteomyelitis. [Resident #15] was evaluated by the provider and has determined to lack medical capacity. She has a sister who is involved in her care. She has a BIMS [Brief Interview for Mental Status] score of 9. [Resident #208] is a long-term resident who was admitted on [DATE]. [Resident #208]'s diagnoses include: Alzheimer's Disease, type 2 diabetes, and CKD [chronic kidney disease]. [Resident #208] was evaluated by the provider and determined to lack mental capacity. He had a DHHR [Department of Health and Human Resources] surrogate who is involved in his care. He had a BIMS score of 6. On 02/2/24, the resident reported another resident wandered into her room in the early morning and touched her inappropriately. [Resident #15] did not initially report this situation to the night shift staff other than reporting a man was wandering into her room. When [Resident #15] made the full allegation that a resident touched her inappropriately, an investigation was initiated. The alleged perpetrator was identified as [Resident #208] and he was immediately placed on one on one supervision. [Resident #15] was interviewed immediately by ANHA [Assistant Nursing Home Administrator] regarding the unwanted touching. [Resident #15] was unable to recall the individual's name but she did report that he is a resident at this facility. [Resident #15] reported that the resident came into her room a total of 3 times. She reported she told him he was in the wrong room and he would leave. However, on the 3rd time he entered her room, he came over to her bed and touched her breast and reached under the covers and touched her private area. She stated he never went under her brief or her shirt. He never touched her skin and didn't touch her vagina. She stated he put his hand on her PEG tube and she was scared he might pull it out. She was able to push her call light and staff immediately entered the room. She didn't report he touched her to staff at that time. The resident was offered a room move and accepted. The [city] Police Department was notified and they arrived to interview [Resident #15]. Based on an interview with the resident, [city] PD [police department] offered intervention by hospital to be evaluated and resident/RP [Responsible Party] both denied medical intervention from outside medical provider at that time. Facility medical provider and RN [Registered Nurse] Unit Manager did complete assessment of resident on 2/2/24 related to alleged incident with no concerns identified. On 2/5/24, [Resident #15]'s Responsible Party called the facility and requested that [Resident #15] go to the hospital for a full gynecological/trauma examination because of her own guilt. The Facility Medical Provider, RN UM [unit manager] and ANHA spoke with sister at that time and the sister still expressed a desire for her to be sent to the hospital. [Resident #15] was sent to the emergency room department at [hospital] for an examination. The resident was not treated for any concerns related to a sexual encounter/sexual trauma while at [hospital]. While at the hospital, resident reported to hospital staff that another resident assaulted her, she screamed and hit her button, the nurses came to her room and called the police. She also reported to the hospital staff that her tube feeding site was bleeding at that time. The alleged perpetrator was put on one on one supervision from staff 24 hours a day, 7 days a week when notified of the alleged incident and remains on one on one supervision at this time. Staff interviews were conducted with the staff who were working on the night shift into day shift of the alleged incident, with reports that resident did not report the alleged incident to them but that she did share he had come into his room but when asked to leave he did so. Description of [Resident #208] was given to the RN Unit Manager and the resident was identified based on description. Interviews with staff revealed that no staff were aware of the alleged inappropriate touching incident until after the day shift came on shift and [Resident #15]'s responsible party notified staff via phone. Staff statements also revealed that they had not witnessed any concerning inappropriate behaviors from [Resident #208], that he does ambulate on the unit but is easily redirectable and will not go beyond other resident doorways when looking for his room. [Resident #208] was interviewed who had no recollection of going into another resident's room. Residents who reside in the unit, including roommate of [Resident #208] were interviewed with no concerns related to [Resident #208]. [Resident #15]'s roommate was interviewed and stated that the privacy curtain was pulled, she heard her roommate tell someone to get out of the room but she thought that whoever was in the room had then left the room. Referrals have been sent out for long term care to multiple facilities for placement with all referrals being denied at this time. The resident had been referred to an inpatient psych facility for a temporary stay out of the facility while the facility continues to seek long term placement elsewhere. [Resident #208] had a medication review by the provider and an order was received on 2/2/24 for Depo-Provera Intramuscular Suspension 150 mg [milligrams]/ml [milliliter] once weekly for behaviors. [Resident #208]'s responsible party is Adult Protective Services [name]. She has been aware and kept in close contact for referrals and any needed medication changes. Facility is unable to substantiate sexual inappropriate behavior between residents. A note was written by Family Nurse Practitioner #186 on 02/02/24. The note, in part, stated, .Chief Complaint / Nature of Presenting Problem: Resident stated she was assaulted by another resident. Investigation by nursing facility is being done as well as appropriate reporting . ROS [review of symptoms] was mainly focused on physical and mental aspects of her experience she stated the male resident had come into her room and left once. The male resident again entered and touched her breasts through her clothing. Stated he then touched her private area through her clothing. Male resident then raised shirt and started to touch PEG [percutaneous endoscopic gastrostomy] tube at which point resident states she began to scream. She stated he then appeared scared and walked to the curtain and eventually left room .Physical Exam: General appearance - Resident is a frail, elderly female. She is lying comfortably in bed during exam. Resident relayed her story to examiner with [name] (unit manager) and then skin exam was completed. There is no bruising or marks to the resident's skin. There are no signs of pressure or open areas. Resident herself states he touched her only through clothing. Per nursing report denied going to hospital for an assault exam. Spoke to resident at length. She states that she was very tearful when it happened but is somewhat better now. She states she is strong and appreciates all the help she has received from staff. States that it has not affected her mental health except for directly after but she does admit to history of having ups and downs. Denied needs at this point, reminded resident if she needed to talk further she had many avenues available to her. On 02/05/24, Resident #15 was evaluated for physical injury related to sexual abuse. The emergency room records state, The patient reports another tenant assaulted her in her bed, she screamed and hit her button, and the nurses came in her room and called the police. She reports she did not want to come to be evaluated then due to her feeding tube. She reports her tube site was bleeding during the assault and also reports a history of multiple kidney stones. Examination in the emergency room showed no bleeding at the PEG tube site. Computed Tomography (CT scan) showed numerous renal calculi (kidney stones). The emergency room discharge diagnoses were 1. Status post assault without significant injury. 2. Large right ureteral stone. On 03/12/24, the following incident was reported: The resident, [Resident #15], told her legal council today, 3/12/24 that she is changing her statement from the 2/2/24 incident statement that claimed the alleged perpetrator, touched her breast and reached under her cover and touched her private area but stating he never went under her clothes or brief nor touched her skin, but did put his hand over the PEG tube area and that is what scared her. To her current statement of, allegedly stating per her lawyer, there was digital vaginal penetration during the incident from 2/2/24. Per her council, facility staff are not allowed to speak to [Resident #15] regarding the facts of the case from 2/2, thus making it impossible for facility staff to interview her or obtain further statements. The ombudsman has been contacted for further assistance since facility staff are unable to speak with the resident regarding the new change in statement. [City] Police have been contacted regarding the change in statement. Alleged perpetrator has not resided in the facility since 2/29/24 and was 1:1 or at a psychiatric hospital from incident allegation 2/2 until discharge. The five (5) day follow up stated as follows: On 03/13/24, [Resident #15]'s legal council [sic] reported to the [facility company] legal counsel that [Resident #15] is changing her original statement from an incident that occurred on 2/2/24. APS, Ombudsman, OHFLAC and [city] Police Department were notified. [Resident #15] is a long-term resident who was admitted on [DATE]. [Resident #15]'s diagnoses include epilepsy, dementia, unspecified protein-calorie malnutrition, and chronic osteomyelitis. [Resident #15] was evaluated by the provider and has determined to lack medical capacity. She has a sister who is involved in her care. She has a BIMS [Brief Interview for Mental Status] score of 9. On 2/2/2024, a referral was made by [Resident #15] to facility staff regarding sexual touching and the incident was faxed to APS, OHFLAC, Ombudsman, and [city] Police Department. [Resident #15]'s original statement claimed the alleged perpetrator, touched her breast and reached under her cover and touched her private area but stating he never went under her clothes or brief nor touched her skin, but did put his hand over the PEG tube area and that is what scared her. The new statement made by [Resident #15]'s Legal counsel now alleges there was digital vaginal penetration during the incident from 2/2/24. Per [Resident #15]'s council [sic], facility staff are not allowed to speak to [Resident #15] regarding the facts of the case from 2/2/24 and staff were not able to obtain any statements from [Resident #15] regarding the change in her statement, however facility did refer [Resident #15] to the Ombudsman for resident advocacy. The facility also called the [city] Police Department and was put in touch with the Detective on the case and was informed the police will likely not return to the facility to reinterview [Resident #15] since she has legal representation and the detective stated [Resident #15]'s council [sic] had been in touch with him. Staff have been interviewed regarding the change in statement with all interviews revealing no staff were ever told by (Resident #15's name) that she was digitally penetrated at the original incident of 2/2/24. The alleged perpetrator has been discharged from the facility permanently since 2/29/24. On 03/25/24, a PHQ-2 to 9 evaluation was conducted to screen Resident #15 for depression. Resident #15 reported feeling down, depressed or hopeless 7-11 days during the past 14 days. Resident #15 reported trouble falling or staying asleep, or sleeping too much 2-6 days during the past 14 days. Resident #15 reported feeling tired or having little energy 2-6 days during the past 14 days. Resident #15 reported poor appetite or overeating 2-6 days during the past 14 days. The resident's score of 5 indicated mild depression. b) Resident #208 Review of Resident #208's medical records showed the resident was admitted to the facility on [DATE]. The resident's MDS assessment with ARD 04/10/20 showed the resident had a BIMS score of 10, which suggested the resident was moderately cognitively impaired. The resident had a diagnosis of Alzheimer's Disease. On 10/07/20, the following care plan focus was initiated, [Resident #208] has a tendency to exhibit sexually inappropriate behavior related to: Cognitive loss/Dementia. A progress note written by Licensed Practical Nurse #184 on 11/09/20 at 8:40 AM regarding Resident #208 stated, Res [resident] has been awake throughout the night going in and out of his room multiple times every few minutes slamming his door behind him. Res has been pacing up and down the hall stopping and looking in rooms at other residents as he was walking the hall. Throughout the night res attempted to go in other residents' rooms several times but was easily redirected by staff but for a short time before he would attempt again. Around 5:30 this morn [morning] this nurse was [sic] CNA were with another resident when this resident was found to be kissing co-res in the mouth for a long period while hugging her and rubbing her head. This nurse approached res to redirect him when he raised his voice at this nurse shaking his fist saying leave me alone I'll do what I want. Res then stomped his feet as he walked back to his room. Review of physicians' orders showed an order for cimetidine, 400 mg twice a day. Cimetidine (Tagamet) is an anti-ulcer medication that is also used to reduce sexual desire. Resident #208's order for Cimetidine stated he was receiving the medication for gastroesophageal reflux disease. Resident #208 continued this dose of Cimetidine until 08/26/21. On 08/26/21, the dosage was decreased to 200 mg twice a day as a gradual dose reduction. Cimetidine was discontinued on 10/21/21. Resident #208's MDS assessment with ARD 10/15/21 showed the resident had a BIMS score of 8, which suggested the resident was moderately cognitively impaired. Resident #208's MDS assessment with ARD 01/08/21 showed the resident had a BIMS score of 10, which suggested the resident was moderately cognitively impaired. On 02/09/21, the following incident involving Resident #208 and Resident #210 was reported, Residents both found in male resident's room. Aide alleging both residents had pants down and appeared to be engaging in sexual activity. Facility unsure of who is perpetrator/victim. A typed unsigned note with the reportable stated, [City] PD [police department] notified 2/9. Officer [name] reported to facility approx. [approximately] 11:30 AM and met with CED [Center Executive Director], SW [Social Worker], and CNE [Center Nursing Director] to discuss incident. Officer stated that he would report to dispatch and follow-up after facility investigation if needed. The five (5) day summary stated, See attached but no narrative summary was included with the reportable provided during the annual survey. A nursing note written in Resident #208's medical records by Licensed Practical Nurse #184 on 02/08/21 at 10:00 PM stated, CNA [Certified Nursing Assistant] came to this nurse stating that near dinner time close to 5 PM that she entered this res [resident] room and heard talking coming from his bathroom. She states she knocked on bathroom door and entered to check o this res and saw this res and female res from room [room number] standing by the sink facing each other. CNA continued saying this res was hugging all over' resident's upper body area and kissing around her face. CNA states this resident's pants were down and female resident's pants were down and that this resident was thrusting his lower body area onto female's lower body area. CNA states she intervened and redirected residents apart from each other by walking female resident out of this res room. CNA states that this res began yelling at her to get out and that this was none of her business. This res stayed in his room as CNA walked female resident out of her room separating both residents without further incident. Immediate supervisor notified of situation. A nursing note written in Resident #210's medical records by Licensed Practical Nurse #184 on 02/08/21 at 10:00 PM stated, CNA approached this nurse stating that around dinner time she entered male resident's room [room number] and upon hearing voices coming from the bathroom she entered the bathroom and found male resident and this resident standing by the sink facing each other. CNA states both residents' pants and underwear were down and male res was hugging and touching this res upper body area and kissing around her face. CNA also states that male res was thrusting his lower body area to this res lower body area. CNA was able to hold this res hand and walk her out of co-residents's room without further incident. Staff denies this res appearing to be under any acute distress during and after incident. Immediate supervisor notified. A nursing note written by Registered Nurse #185 on 02/09/21 at 12:15 PM regarding Resident #208 stated, Resident placed on 1:1 supervision during investigation for safety. Physicians' orders showed an order written on 02/09/21 for 1:1 supervision for safety, every shift. The order was discontinued on 02/10/21, and an order for every 15 minute visual checks for safety, duration of 72 hours. A progress note written by Licensed Practical Nurse #187 on 06/02/21 at 2:05 AM regarding Resident #208 stated, Resident was observed in another female resident's room. Resident was holding female resident's hands when observed. Resident gave no excuse why he was in the other resident's room. He was escorted out and returned to his room. Will continue to monitor. Resident #208's MDS assessment with ARD 09/10/21 showed the resident had a BIMS score of 5, which suggested the resident was severely cognitively impaired. A progress note written by LPN #190 on 11/11/21 at 7:07 PM regarding Resident #208 stated, Reported to this nurse from female residents that resident was standing in his doorway grabbing his pants in the private area. This nurse reported it to oncoming nightshift nurse. Spoke to resident and explained to him that is was inappropriate. Verbalized understanding. Review of physicians' orders showed an order written on 11/12/21 for every 15 minute visual checks which continued through 11/30/21. A progress note written by LPN #187 on 11/19/21 at 6:52 PM regarding Resident #208 stated, Resident is monitored continuously. Continues to wander at night wanting coffee and going through the halls into female residents rooms. Resident was reported being observed in room [number] standing, staring at incapacitated resident. A progress note written by LPN #187 on 11/20/21 at 10:34 PM regarding Resident #208 stated, Mental Health/Behavior reviewed. Physical behaviors, directed toward others occurs up to 5 days a week. Wandering occurs daily or almost daily and poses significant risk and/or is intruding on others. Pt. is experiencing agitation/restlessness. Pt. is experiencing anxiety about surroundings. Pt. has had sleep-cycle issues daily or almost daily. Additional mental health/behavior comments: Due to 15 min [minute] checks resident does not have opportunity to wander or go in other resident rooms. If no one is in the vicinity when exiting his room he will wander to other resident's rooms. Usually female. A progress note written by LPN #187 on 11/21/21 at 10:05 PM regarding Resident #208 stated, Resident was observed in attempting to kiss a disabled resident. Resident was told to stop and to return to his room. Resident stopped what he was doing and returned to his room. Resident #208's MDS assessment with ARD 12/10/21 showed the resident had a BIMS score of 5, which suggested the resident was severely cognitively impaired. On 12/23/21, the following incident was reported, Resident [#208] was found in co-resident's [#209] room with penis out attempting to put it into co-resident's mouth. According to the report, Resident #208 was placed on one-on-one observation and investigation was initiated. A handwritten note in the incident investigation signed by a Social Worker, signature illegible, stated, Reported to [city name] PD [police department] on 12/23. Two officers came to facility do discuss (Officer [name] and Officer [name].) Reviewed allegation and medical/mental status of both residents. Officer called this SW [Social Worker] on 12/29 to follow-up on outcome of investigation. Unable to prosecute d/t [due to] mental capacity of perpetrator. Case closed at this time. The five (5) day incident follow-up reported, On December 22nd 2021, co-resident [Resident #208] allegedly had his penis out and was attempting to put into resident [Resident #209] mouth. Allegation of potential abuse was reported to OHFLAC [Office of Health Facility Licensure and Certification], APS [Adult Protective Services] and Ombudsman; investigation initiated. [City] Police Department also notified. [Resident #209] is a long term resident of [facility] that admitted to the facility in October 2021. She has diagnosis of traumatic brain injury, unspecified intellectual disabilities, and mild cognitive impairment. [Resident #209] is non-verbal, unable to communicate and is dependent on staff for all activities of daily living. She lacks the capacity to make her own medical decisions and her cousin is resident's health care surrogate and active in her care. [Resident #209] is unable to be interviewed as she is non-verbal and unable to understand or communicate. Interview with resident's roommate indicated that she is unable to remember co-resident entering the room. Interviews with staff members indicate that the resident was re-directed out of the room immediately and no physical activity occurred. [Resident #209] and roommate show no signs or symptoms of distress following the incident. Male co-resident has diagnosis of Alzheimer's disease with a BIMS [brief interview for mental status] of 5 and is care planned for sexually inappropriate behaviors related to limited cognition. Resident placed on 1:1 supervision immediately following the incident with no further concerns noted. Resident was seen by provided on 12/23/21 with new orders for Sertraline and melatonin at night along with labs to check for an illness that may contribute to behaviors. Medication review was completed for resident by Medical Director on 12/27/21 with new orders for Cimetidine for sexual intrusiveness. Resident continues on 1:1 supervision at this time which will be reevaluated by IDT [interdisciplinary team] and provided. Allegation of abuse unsubstantiated. No intentional abuse indicated as the alleged perpetrator lacks capacity to understand appropriate behavior. Handwritten sheets accompanying the reportable document that a resident was on 1:1 observation from 12/22/21 at 8:30 PM through 01/04/22. The resident's name was not on the form. Additional handwritten sheets accompanying the reportable document Resident #208 was on 15 minute visual checks from 12/23/21 at 12:00 AM through 01/03/22 at 11:45 PM. A nursing note written on 12/23/21 at 12:07 PM by Social Worker #183 stated, Spoke with [Health Care Surrogate] regarding incident with [Resident #209]. Discussed options for alternative placement due to safety concerns. Discussed option of an all male Adult Family Care Home. HCS [Health Care Surrogate] to fax paperwork for SW [Social Worker] to complete for possible placement in an all male AFC [Adult Family Care] home. Resident has no family/friends in the area so HCS will submit the application to all available homes in WV. A progress note written by LPN #187 on 12/23/21 at 12:11 AM stated, Mental Health/Behavior reviewed. Physical behaviors, directed towards others occurs daily or almost daily. Verbal behaviors, directed toward others occurs up to 5 days a week. Wandering occurs daily or almost daily and poses significant risk and/or is intruding on others. Pt. is experiencing agitation/restlessness. Pt. is experiencing anxiety about surroundings. Pt. is experiencing impulsive behavior. Inappropriate behaviors towards females. Exhibits behavior hyperactivity (e.g. restless walking patterns). Exhibits behaviors: frustration. Review of the physicians' orders showed Cimetidine 400 mg, twice a day, for sexual intrusiveness was started on 12/27/21. A social services note written on 01/03/22 stated referrals to transfer the resident were sent to two (2) facilities. A progress note written on 01/04/22 at 12:46 PM by Social Worker #188 stated, Spoke with admissions at [name]. Referral denied as facility is not taking admissions at this time. A progress note written by Administrator #189 on 01/04/22 at 11:52 AM stated, IDT [interdisciplinary team] review of resident due to sexual abuse allegation. Resident has remained on 1:1 supervision since allegation was made. Resident was seen by provider on 12/23 with new orders for Sertraline (Zoloft) to be increased from 150 mg per day to 200 mg per day and start Melatonin 5 mg per day. Resident's medications were reviewed by Medical Director on 12/27 with new order for Cimetidine 400 mg twice a day. Resident is currently receiving psych services. HCS [health care surrogate] requested referrals to be sent to [outside facility] and [outside facility] of [city] which have been sent at this time. MD gave order to discontinue 1:1 supervision and conduct 15 minute safety checks at this time. An order for 15 minute visual checks for safety was written on 01/04/22 and continued until 06/06/22. A progress note written by Social Worker #188 on 01/12/22 at 2:24 PM stated, Spoke with [outside facility] admissions this date. Referral was denied at this time. On 05/26/23, Resident #208 was transferred to the hospital following a fall. Cimetidine (Tagamet) was not continued after his return to the facility on [DATE]. Resident #208's MDS assessment with ARD 12/31/23 showed the resident had a BIMS score of 6, which suggested the resident was severely cognitively impaired. A progress note written by FNP (family nurse practitioner) #186 on 01/24/24 at 2:52 PM regarding Resident #208 stated, in part, Approximately 2 weeks ago resident on unit, per another resident he pulled his pants down in front of her and showed himself. Per staff behavior has been increasing in frequency .Added Tagamet 200 BID [twice a day] for sexual behavior. A progress note written by FNP #186 on 02/02/24 at 3:04 PM regarding Resident #208 stated, in part, Resident has been accused of assault on another resident of the facility. Due to increased behaviors [name] his DHHR representative was called. She was informed of wishes to start resident on Depo-Provera IM [intramuscular] injections. Educated on use to help subdue sexual behavior by staff of facility on group call .Resident is currently a one on one due to behaviors. Review of physicians' orders showed an order was written on 02/02/24 that stated, Resident will be under 1:1 supervision at all times due to inappropriate sexual behaviors every 12 hours. This order was in effect at the time of the resident's discharge from the facility. A progress note written by LPN #32 on 02/07/24 at 11:49 AM regarding Resident #208 stated, While 1 on 1 was watching resident, resident walked to the door of his room and grabbed his penis through pants ant shook it at passing resident. Charted in behavior book. A progress note written by LPN #32 on 02/07/24 at 2:41 PM stated, Has not wandered into any one else's room since becoming 1:1 but still is grabbing himself and saying inappropriate things [TRUNCATED]

Based on resident interview, medical record review and staff interview, the facility failed to ensure residents were free from abuse and neglect. A facility staff member failed to transfer Resident #72 as directed by the care plan resulting in the actual harm of a fracture of the left shoulder. In addition, the facility was aware of and failed to acknowledge an allegation of abuse voiced by Resident #55. This was true for two (2) of three (3) residents reviewed for the care area of abuse and neglect. Resident identifiers: #72 and #55. Facility census: 141. Findings included: Facility Policy titled, OPS300 Abuse Prohibition revision date: 07/01/2019. This policy states, Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect the designee will perform the following: -Enter allegation into the risk management system. -Report the allegation no later than 24 hours after the allegation is made (if the event did not result in serious bodily injury. - Notify Licensing Boards and Registries. -Initiate an investigation within 24 hours of the allegation. -The investigation will be thoroughly. a) Resident #72 Review of Resident #72's medical record revealed a progress note written on 04/03/21 at 11:38 AM, which stated, Received xray results. Acute fracture involving left humeral neck with modest displacement. Reported to (doctor's name). No new orders at this time. Needs to follow up with house physician. A physician's note written on 04/03/21 at 1:06 PM, stated Pt (patient) was being transferred from chair to bed when a loud pop sound was heard and pt [patient] immediately started experiencing pain in her left shoulder. Pt c/o (complaint) if at rest does not hurt but limited ROM [range of motion], active or passive, causes her pain. Pt is a long term resident at facility. Pt receives [MEDICATION(S)] for pain. A progress note written on 04/04/21 at 11:53 AM stated, Spoke with son, (son's name), to inform him that mother's arm does have a fx (fracture). He wants her sent to (hospital name) to be evaluated. Received order to send out from (doctor's name). A progress note written on 04/04/21 at 6:09 PM, stated, Resident returned from [hospital name]. New order for [MEDICATION(S)]-acetaminophen 5-325mg. Sling placed on left arm. Resident to f/u [follow-up] with walk-in ortho clinic within a week. According to the hospital discharge and follow-up instructions on 04/04/21, X-ray revealed proximal left humeral fracture. Discussed with Ortho (orthopedics). Shoulder sling to be worn. Follow-up with Ortho. next week. According to the medical administration record, the resident was receiving pain medication for chronic pain prior to the fracture. On 04/06/21 at 8:07 AM, she received additional pain medication ([MEDICATION(S)]-acetaminophen 5-325mg) for left arm pain. The medication effectively relieved her pain. Resident #72 was seen at the orthopedic clinic on 04/12/21. The orthopedic clinic note stated, .was found to have an impacted minimally displaced fracture of the fracture of the left proximal humerus. On examination, she is diffusely tender on the arm. She has good neurologic function on the hand. She can bend her elbow okay. She has previously had a wrist fracture on the left a number of years ago, which has gone on to heal. She still has a volar plate intact. She has most recently, a year and a half or so ago, she had an impacted right proximal humerus fracture, which has gone on to heal and was seen by (doctor's name). At this point in time, I would recommend doing a sling for comfort, would come out of it when she is sitting upright and let her use the left hand for light activities like eating, drinking, writing, keyboarding. She can use it for any craft work or anything for light activity. The only thing we wanted to avoid is going up overhead until have more time to heal. I would recommend seeing her back in probably 4-6 weeks and get a new x-ray of the left shoulder. Resident #72 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) with Assessment Reference Date (ARD) 03/10/21 documented a Brief Interview for Mental Status (BIMS) score of 5. A lift/transfer/reposition evaluation performed 03/23/21 stated the resident required a gait/transfer belt and needed two (2) staff for repositioning in bed. On 04/20/21 at 1:00 PM, the Director of Nursing (DON) was asked for additional information regarding the incident. The DON provided an incident report which stated the incident occurred on 04/02/21 at 4:00 PM. The incident report stated, CNA (certified nursing assistant) reported to nurse that when transferring resident from wheelchair to bed heard a pop noise. Resident able to perform ROM [range of motion] on all extremities. Denies pain and discomfort. Upper arms even. Skin color normal and intact .Resident with advanced age, history of fractures. Therapy to assess after Orthopedic evaluation. The incident was reported to the physician on 04/03/21 at 4:00 PM. The DON also provided a written statement from Nursing Assistant (NA) #103, dated 04/05/21, which stated, At 3:45 PM I was transferring [sic] [resident's room number and first name] into bed from her wheelchair. With my arms under her armpits, somehow her arm slipped up. (left arm) and made a popping sound. I then got her in the bed. The DON also provided a statement from Resident #72, dated 04/05/21, which stated, (NA name) pulled her up under L (left) arm to pull her up in bed. Resident states she felt and heard a pop. Denies pain on event, but states she started feeling pain 04/03. Denies fall, abuse, or intentional injury. Resident stated, I know she didn't mean to. She is a fine girl. Statement read back to resident and taken by (Registered Nurse #128). On 04/05/21, NA #103 received Clinical Competency Validation on the following topics: Turn and Reposition the Patient and Gait Belt. Review of Resident #72's comprehensive care plan revealed the focus, Resident/Patient requires extensive assistance/is dependent for ADL (activities of daily living) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to debility. Interventions included as follows: - Provide resident with extensive assistance using gait belt for transfers (initiated 04/20/21) - Provide resident with extensive assist x 2 for bed mobility (initiated 12/14/18) During an interview on 04/20/21 at 2:00 PM, the Administrator was asked if the incident had been reported to state agencies as potential abuse or neglect. The Administrator stated that, due to the resident's statement, the incident had not been reported to state agencies. The Administrator was also asked if any further investigation had been conducted due to the resident's lift/transfer/reposition evaluation and the differing accounts of the incident by the CNA and the resident. The administrator had no additional investigation to provide. As a result of the nurse aide not following the care plan for the use of a gait belt and 2 person assist with transfers, the resident suffered an acute fracture involving left humeral neck with modest displacement resulting in pain requiring additional pain medication. On 04/20/21 at 3:30 PM, the administrator stated that, upon further consideration, the incident was reported today to Adult Protective Services, the Nurse Aide Registry, the ombudsman, and the Office of Health Facility Licensure and Certification after surveyor intervention. b) Resident #55 During an interview on 04/19/21 at 11:28 AM, Resident # 55 said, Nurse Aide (NA) #40 was mean to me. She was asked, when was he mean to her? She said, a week or so ago. She went on to say, he can't help me anymore because he can't come in my room anymore. On 04/19/21 at 3:05 PM, Resident # 55 said she remembers what NA #40 said to her now. She said, she had her call light on and she saw him walk by her door. She asked him to help her and he said No, real hateful and said, I'm not dealing with you all day today. During an interview with Registered Nurse (RN) #38 on 04/20/21 at 1:45 PM, she was asked about NA #40 not being allowed in the room of Resident #55. RN #38 stated she was not aware. She said, the Unit Manager would know. On 04/20/21 at 1:56 PM, Unit Manager (UM) #96 was asked if Resident #55 had reported to her about NA #40 being mean to her and refusing to provide care. She stated Resident #55 makes lots of accusations. She said, she told NA #40 not to go in the room of Resident #55 anymore. She went on to say this happened about two (2) weeks ago. She was asked what the policy instructs her to do when there is an allegation of abuse. She stated, she would let the Social Worker (SW) # 116 know and it would be investigated. She was asked if she reported the allegation to SW # 116. UM #96 stated, yes. At approximately 3:00 PM on 04/19/21, a review of the facilities reportable incidents and allegations revealed no reportable allegations of abuse for Resident # 55. During an interview on 04/20/21 at 2:07 PM, SW #116 was asked about receiving an allegation from Resident # 55 regarding NA # 40 being mean to her and refusing to help her in the last couple of weeks. She said she does not remember any and that if so it would be in the reportable book. On 04/20/21 at 2:10 PM, the Administrator was made aware of the findings and the failure to report and investigate the allegations made by Resident #55.

Based on observation, medical record review and staff interview, the facility failed to ensure residents receive adequate supervision and assistive devices to prevent accidents. Facility staff failed to follow orders to ensure a safe transfer for Resident #72. As a result, Resident #72 sustained a fractured shoulder. In addition, Resident #48 did not have interventions in place to address falls. This was true for two (2) of six (6) residents reviewed for the care area of accidents and falls. Resident identifiers: #72 and #48. Facility census: 141. Findings included: a) Resident #72 On 04/19/21 at 11:45 AM, Resident #72 was noted to be lying in her bed. The resident denied pain or any other complaints at that time. Review of Resident #72's medical record revealed a progress note written on 04/03/21 at 11:38 AM, which stated, Received xray results. Acute fracture involving left humeral neck with modest displacement. Reported to (doctor's name). No new orders at this time. Needs to follow up with house physician. A physician's note written on 04/03/21 at 1:06 PM, stated Pt (patient) was being transferred from chair to bed when a loud pop sound was heard and pt [patient] immediately started experiencing pain in her left shoulder. Pt c/o (complaint) if at rest does not hurt but limited ROM [range of motion], active or passive, causes her pain. Pt is a long term resident at facility. Pt receives [MEDICATION(S)] for pain. A progress note written on 04/04/21 at 11:53 AM stated, Spoke with son, (son's name), to inform him that mother's arm does have a fx (fracture). He wants her sent to (hospital name) to be evaluated. Received order to send out from (doctor's name). A progress note written on 04/04/21 at 6:09 PM, stated, Resident returned from [hospital name]. New order for [MEDICATION(S)]-acetaminophen 5-325mg. Sling placed on left arm. Resident to f/u [follow-up] with walk-in ortho clinic within a week. According to the hospital discharge and follow-up instructions on 04/04/21, X-ray revealed proximal left humeral fracture. Discussed with Ortho (orthopedics). Shoulder sling to be worn. Follow-up with Ortho. next week. The resident was receiving pain medication for chronic pain prior to the fracture. On 04/06/21 at 8:07 AM, she received additional pain medication ([MEDICATION(S)]-acetaminophen 5-325mg) for left arm pain. The medication effectively relieved her pain. Resident #72 was seen at the orthopedic clinic on 04/12/21. The orthopedic clinic note stated, .was found to have an impacted minimally displaced fracture of the fracture of the left proximal humerus. On examination, she is diffusely tender on the arm. She has good neurologic function on the hand. She can bend her elbow okay. She has previously had a wrist fracture on the left a number of years ago, which has gone on to heal. She still has a volar plate intact. She has most recently, a year and a half or so ago, she had an impacted right proximal humerus fracture, which has gone on to heal and was seen by (doctor's name). At this point in time, I would recommend doing a sling for comfort, would come out of it when she is sitting upright and let her use the left hand for light activities like eating, drinking, writing, keyboarding. She can use it for any craft work or anything for light activity. The only thing we wanted to avoid is going up overhead until have more time to heal. I would recommend seeing her back in probably 4-6 weeks and get a new x-ray of the left shoulder. Resident #72 had diagnoses including, but not limited to, cerebral ischemia, [CONDITION(S)] and [CONDITION(S)] following cerebral infarction, and [CONDITION(S)]. The Minimum Data Set (MDS) with Assessment Reference Date (ARD) 03/10/21 documented a Brief Interview for Mental Status (BIMS) score of 5. A lift/transfer/reposition evaluation performed 03/23/21 stated the resident required a gait/transfer belt and needed two (2) staff for repositioning in bed. On 04/20/21 at 1:00 PM, the Director of Nursing (DON) was asked for additional information regarding the incident. The DON provided an incident report which stated the incident occurred on 04/02/2021 at 4:00 PM. The incident report stated, CNA (certified nursing assistant) reported to nurse that when transferring resident from wheelchair to bed heard a pop noise. Resident able to perform ROM [range of motion] on all extremities. Denies pain and discomfort. Upper arms even. Skin color normal and intact .Resident with advanced age, history of fractures. Therapy to assess after Orthopedic evaluation. The incident was reported to the physician on 04/03/21 at 4:00 PM. The DON also provided a written statement from Nursing Assistant (NA) #103, dated 04/05/21, which stated, At 3:45 PM I was transferring [sic] [resident's room number and first name] into bed from her wheelchair. With my arms under her armpits, somehow her arm slipped up. (Left arm) and made a popping sound. I then got her in the bed. The DON also provided a statement from Resident #72, dated 04/05/21, which stated, (NA name) pulled her up under L (left) arm to pull her up in bed. Resident states she felt and heard a pop. Denies pain on event, but states she started feeling pain 04/03. Denies fall, abuse, or intentional injury. Resident stated, I know she didn't mean to. She is a fine girl. Statement read back to resident and taken by (Registered Nurse #128). On 04/05/21, NA #103 received Clinical Competency Validation on the following topics: Turn and Reposition the Patient and Gait Belt. Review of Resident #72's comprehensive care plan revealed the focus, Resident/Patient requires extensive assistance/is dependent for ADL (activities of daily living) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to debility. Interventions included as follows: - Provide resident with extensive assistance using gait belt for transfers (initiated 04/20/21) - Provide resident with extensive assist x 2 for bed mobility (initiated 12/14/18) During an interview on 04/20/21 at 2:00 PM, the Administrator was asked if the incident had been reported to state agencies as potential abuse or neglect. The Administrator stated that, due to the resident's statement, the incident had not been reported to state agencies. The Administrator was also asked if any further investigation had been conducted due to the resident's lift/transfer/reposition evaluation and the differing accounts of the incident by the CNA and the resident. The administrator had no additional investigation to provide. As a result of the nurse aide not following the care plan for the use of a gait belt and 2 person assist with transfers, the resident suffered an acute fracture involving left humeral neck with modest displacement resulting in pain requiring additional pain medication. On 04/20/21 at 3:30 PM, the administrator stated that, upon further consideration, the incident was reported today to Adult Protective Services, the Nurse Aide Registry, the ombudsman, and the Office of Health Facility Licensure and Certification after surveyor intervention. b) Resident #48. During the initial tour of the facility on 04/19/21 at 01:12 AM, a fall mat was observed to be propped up against the exterior wall of Resident #48's room. Resident #48 had one fall mat laying on the left-hand side of his bed. A review of Resident 48#'s medical record revealed the following order dated 01/24/20: Low bed and fall mats at bedsides while resident is in bed. every day and night shift. Review of Resident #48's care plan found a focus problem: (NAME) is at risk for falls and actuals falls related to CVA, unsteady gait, weakness in lower extremities and administration of [CONDITION(S)] medication. (NAME) is known to crawl out of the bed onto the floor. The goal associated with this problem: Resident will have no falls with injury resulting in ER visit throughout the quarter. Interventions included: Assess fall mats for proper placement at bedside. Low bed with bilateral fall mats while in bed. On 04/19/21 at 1:14 PM, Licensed Practical Nurse (LPN)# 169, was asked to enter Resident #48's room. LPN #169 stated that the fall mat should always be down beside his bed when he is in it. LPN #169 put the fall mat down beside Resident # 48's bed at this time. No other information was provided by the end of the survey on 04/21/21 at 6:30 PM.

Based on record review, staff interview, observation and infection control policy review, the facility failed to maintain an effective infection control program to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. The facility failed to effectively implement isolation practices for Resident #149. Resident #149, who was diagnosed with [REDACTED].#108) who did not [MEDICAL CONDITION] or [MEDICAL CONDITION] [DIAGNOSES REDACTED].#149 would pick scabs from her open [MEDICAL CONDITION] and flick them about. Resident #108 was unable to understand the need for, and to independently practice hygienic measures such as handwashing. Resident #108 ambulated about the room, touching various environmental objects, and about on the nursing unit at will. This had the potential for Resident #108 to become a vector for Resident #149's infectious disease processes, carrying infective material where other residents, staff, and visitors might have contact. These findings were determined to pose an immediate jeopardy to the health and well-being of others. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC) on 04/25/18 at 12:48 PM and preparation of a written statement regarding the identified deficient practice, the Administrator and Director of Nursing (DoN) were notified of this immediate jeopardy on 04/25/18 at 1:28 PM. The facility provided an acceptable Plan of Correction at 3:45 pm on 04/25/18. After determining the facility had implemented its plan of correction, the immediate jeopardy was abated on 04/25/18 at 3:53 pm After removal of the immediate jeopardy, a deficient practice, with the potential to affect more than a limited number of residents, remained at a scope and severity of E. A nurse administered medications to Resident #44 after dropping them on the medication cart, picking them up with her bare hands, and placing them in a medication cup with other medications. For Resident #99, observations of incontinence care identified breaches of technique that increased the potential for urinary tract infection. Resident Identifiers: #149, #108, #44, and #99. Facility census: 156. Findings included: a) Resident #149 An observation on 04/23/18 at 10:59 AM, noted a sign on a resident's door, See nurse before entering room. Licensed Practical Nurse (LPN) #92 said the resident was in contact isolation because she had [MEDICAL CONDITION] in her nose in the hospital and all the opened sores on her body. She also identified the resident was [MEDICAL CONDITION] positive. It was also noted there was another resident in the room. LPN #92 said that her roommate did not [MEDICAL CONDITION] or [MEDICAL CONDITION]. On 04/23/18 at 11:00 AM, observations found Resident #149 sleeping with her head resting on the side rail. She had multiple opened and scabbed over areas on all exposed skin, some were actively bleeding. Observation on 04/23/18 at 2:28 PM, found Resident #149 awake, sitting on her bed picking at a scabbed area on the top of her head. The curtain between the beds was half open and her roommate was up looking for her TV remote on Resident #149's bedside table. An observation on 04/23/18 at 3:33 PM, the curtain between the beds was pulled less than half way between the beds. During an interview on 04/23/18 at 3:43 PM, the director of nursing (DoN) said the resident (#149) had [MEDICAL CONDITIONS]. The doctor wanted her to be in contact isolation because she picked at her sores. She added that her roommate did not have a history [MEDICAL CONDITION] or [MEDICAL CONDITION], but did not need to be moved. During an interview on 04/25/18 at 9:06 AM, Infection Control Nurse (ICN) #167 said the attending physician said Resident #149 needed to be in contact isolation and a private room. It was brought it the attention of the Administrator, DoN, and the Admission director. They were in on the conversation about moving one of the residents. She said that they try to keep the curtain pulled, because she knows Resident #149 is always picking at her wounds and flicking bits of the scabs about. When informed that the curtain was not always pulled, because the resident's (in isolation) feet and bottom of the bed could be seen. ICN #167 stated that Resident #108 (Resident #149's roommate) kept pulling the curtain back. During an interview on 04/25/18 at 1:29 PM, the DoN said she was not told the doctor had ordered Resident #149 moved to a private room. Resident #149 was admitted on [DATE] and the physician assessed and ordered Contact Isolation [MEDICAL CONDITION] and [MEDICAL CONDITION] on 04/02/18. Although rooms were available, the facility failed to provide an appropriate room for this resident's isolation needs. Resident #149's roommate, Resident #108, independently ambulated throughout her room and the third (3rd) floor of the facility. Resident #108's Brief Interview for Mental Status (BIMS) was 04, indicating severe cognitive impairment. As Resident #108 ambulated, she encountered her roommate, visitors, staff, and other residents. Resident #108 was unable to comprehend the need for proper hand hygiene and need for infection control measures. Review of records revealed nursing notes that stated Resident #149 was picking at her wounds causing bleeding and redirection did not work. Observations noted staff were diligent about wearing a gown, gloves, and a mask with a shield every time they entered Resident #149's room. In the meantime, Resident #108 lived in this room without anything on to protect her. The facility's failure to provide appropriate infection control procedures for a resident diagnosed with [REDACTED]. A determination of immediate jeopardy situation. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC) on 04/25/18 at 12:48 PM and preparation of a written statement regarding the identified deficient practice, the Administrator and Director of Nursing (DoN) were notified of this immediate jeopardy on 04/25/18 at 1:28 PM. The facility provided an acceptable Plan of Correction at 3:45 pm on 04/25/18. After determining the facility had implemented its plan of correction, the immediate jeopardy was abated on 04/25/18 at 3:53 pm The facility's Plan of Correction, received on 04/25/18 at 2:30 PM, included: Resident #149 was moved to a private room and the contact precautions continue. Resident #149 has Capacity and was reeducated by the Infection Preventionist at 2:45 PM, to avoid picking and flicking scabs and asked to inform nurses if areas are itching. DoN will evaluate Resident #108 by 3:00 PM and will discuss findings with the attending physician for any follow up. All residents of the facility have the potential to be affected. The DoN/designees conducted observation of all residents' requiring contact precautions on 04/25/18 at 1:30 PM, and no additional residents were affected. The Nurse Practice Educator (NPE)/designee will begin to re-educate all center staff on 04/25/18 regarding observation of residents in contact isolation do not expose other center residents to blood or bodily fluids with posttest to validate understanding. Staff not available during this timeframe will be provided re-education including post-test by the NPE/designee, upon returning to work. New hires will be provided education and post-test during orientation by the NPE/designee. The Unit Managers (UMS)/designee will conduct observation of residents in contact isolation daily for two weeks across all shifts including weekends, then three times a week for two weeks, then randomly thereafter to ensure that no other center residents are at risk for exposure to blood or bodily fluids of those in contact isolation. Trend identified will be reported to the DoN monthly to the Quality Improvement Committee (QIC) for any additional follow up and/or in-servicing until the issue is resolved and a randomly thereafter as determined by the QIC. After removal of the immediate jeopardy, a deficient practice, with the potential to affect more than a limited number of residents, remained at a scope and severity of E. A nurse administered medications to Resident #44 after dropping them on the medication cart, picking them up with her bare hands, and placing them in a medication cup with other medications. For Resident #99, observations of incontinence care identified breaches of technique that increased the potential for urinary tract infection. b) Resident #44 On 04/24/18 at 9:45 AM, during observation of medication administration, Licensed Practical Nurse (LPN) #40 opened five (5) oral medications for administration to Resident #44. LPN #40 dropped two (2) of the medications, [MEDICATION NAME] and Eliquis, onto the top of the medication cart. She picked up the [MEDICATION NAME] and Eliquis with her bare hands, placed them into the medicine cup along with the resident's other oral medications, and administered the medications to Resident #44. During an interview on 04/24/18 at 9:54 AM, LPN #40 stated she understood how dropping the medications on the top of the medication cart and then handling them with her bare hands could be an infection control issue. On 04/24/18 at 10:00 AM, when the observation was shared with Unit Manager (UM) #17, UM #17 made no comment regarding the matter. c) Resident #99 Observations on 04/24/18 at 11: 39 AM, noted nurse aide (NA) gathering supplies and providing incontinence care for this resident. NA Employee #86 (E#86) placed several clean, folded washcloths directly into the sink basin, shared with two (2) other residents in this room. She ran warm water from the faucet over them until they were completely submerged. E#86 squeezed out the excess water with her gloved hands, then took them to the resident's bed. The resident was incontinent of soft, semi-formed stool which was contained in the perineal and rectal areas and between her legs. E #86 at first cleaned the resident from the front to the back with one of the washcloths as the resident lay on her left side. She disposed of that washcloth into a clear, plastic bag. When E#86 got to the last washcloth, there was still bowel movement in the vulva/perineal area. She folded over the last, used wash cloth repeatedly, and made three (3) more swipes with that soiled wash cloth to remove the last of the bowel movement from the vulva and perineal area. During an interview with the director of nursing (DON) on 04/25/18 at 6:00 p.m., she said it was against the facility's policy to soak washcloths in a sink basin. She said staff were supposed to use the resident's plastic wash basin for that purpose. The DON also agreed that it was not an acceptable practice to reuse a soiled washcloth to clean the perineal area of an incontinent resident. She said she would do staff education to all staff right away. These findings were shared with the administrator on 04/26/18 at approximately 9:30 a.m. No further information was provided by the facility prior to exit.

Based on observation, resident interview, staff interview, and record review the facility failed to ensure each resident was free from verbal abuse and neglect. The facility failed to provide timely incontinence care to Resident #119. The resident also tearfully reported being verbally abused by a nurse aide because he had called the nurses' station for help after no one responded to his call bell for thirty (30) minutes. The lack of incontinence care and the verbal abuse caused the resident to experience pain, skin breakdown, and psychological harm. Until the surveyor identified the resident's problems and intervened, staff were not aware of the seriousness of his condition. These findings were determined to constitute immediate jeopardy to Resident #119. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC) at 1:25 PM on 04/25/18, and preparation of a written statement, the Administrator and Director of Nursing were notified of the Immediate Jeopardy. The facility provided an acceptable at 4:17 PM on 04/25/18. After verifying implementation of the plan of correction, the immediate jeopardy was abated at 5:26 PM on 04/25/18. No deficient practice remained for this requirement after removal of the immediate jeopardy. This affected one (1) of seven (7) residents reviewed for activities of daily living. Resident identifier: #119. Facility census: 156. Findings included: a) Resident #119 During the initial screening for the Long Term Care Survey Process, an interview on 04/23/18 at 11:37 AM, Resident #119 stated he had a pressure ulcer on his buttock from sitting in urine for 30 minutes or longer. He went on to explain he could not walk, that he tried to use a urinal, but sometimes did not get all of the urine in the urinal. Medical record review found his [DIAGNOSES REDACTED].>- muscle weakness - heart failure - Retention of urine - Type 2 Diabetes underlying condition with hyperosmolarity - Chronic [MEDICAL CONDITIONS] - Obesity - History of pressure ulcers on the right heel and penis According to his minimum data set assessment (MDS) with an assessment reference date (ARD) of ____, his Brief Interview for Mental Status Score (BIMS) was 15, indicating he was cognitively intact. Review of his medical records found no mention of current pressure ulcers. Skin Check Performed Sheets dated from 01/27/18 to 04/23/18 documented the following: - 01/27/18- No Skin Injury/Wounds by Licensed Practical Nurse (LPN) #172 - 02/04/18 -No Skin Injury/Wounds by LPN #92 - 02/10/18- No Skin Injury/Wounds by LPN #172 - 02/17/18- No Skin Injury/Wounds by LPN #92 - 02/24/18- No Skin Injury/Wounds by LPN #172 - 03/03/18- No Skin Injury/Wounds by LPN #92 - 03/10/18- No Skin Injury/Wounds by LPN #172 - 03/17/18 -Yes Skin Injury/Wounds identified No New Skin Injury/Wounds Type of Skin Injury/Wounds Moisture Associated Skin Damage by Registered Nurse (RN) #4 - 03/24/18- No Skin Injury/Wounds by LPN #172 - 04/02/18- No Skin Injury/Wounds by RN #4 - 04/07/18- No Skin Injury/Wounds by LPN #33 - 04/23/18 -No Skin Injury/Wounds by LPN #92 On 04/25/18 at 9:15 AM, Wound Care Nurse #120 agreed to do a complete skin assessment with the surveyor present. On entering the room, Resident #119 was emotional and tearful saying that he was, chewed out, by Nurse Aide #96 for calling the nurses' station with his cell phone. He stated that she told him to only use his call light that was what it was for and not to call the nurses' station again. He said NA #96 told him that he was not the only one on this floor and he just needed to wait his turn. He said he responded by telling her he used the call light and had been waiting for more than 30 minutes before he called the nurses' station with his cell phone because his skin was on fire from sitting in urine. Resident #119 told this to the surveyor, Wound Care Nurse #120, and Nurse Aide #84. With the resident's permission, Wound Care Nurse #120 pulled the sheets back revealing a very large red excoriation on his upper outer thighs. Further investigation found areas of broken skin under his scrotum and coccyx. The resident's tee shirt was saturated with urine up his back and had small amount of stool on the bottom. The resident said NA #96 had changed him, therefore the nurse aide left him with a soiled shirt. Wound Care Nurse #120 removed the resident's tee shirt. When the nurse asked how long his skin had been in this condition, the resident replied it had been a year - that it started after being on this floor for a week. The complete skin audit by Wound Care Nurse #120 found: - 1. Pressure Ulcer Stage II on Coccyx - 2. Pressure Ulcer Stage II on right ear - 3. Excoriated areas bilateral groin, under both breast, bilateral abdominal folds, bilateral upper outer thighs and bilateral calf's. - 4. Reddened area to the right great toe, second and third toes, right heel. During an interview on 04/25/18 at 9:35 AM, Wound Care Nurse #120 stated that he was, Just mortified by what was just discovered, referring to the condition of Resident #119's skin. He went on to say he had no excuse and they had failed this resident. On 04/25/18 at 9:45 AM, the DoN was informed of the findings for Resident #119. She said she was already aware and was working on a plan of correction. On 04/25/18 at 1:10 PM, Resident #119 said that he was still upset over the NA #96 fussing at him that morning and it was not the first time he had had to wait for over 30 minutes for assistance. He went on to say he had called his wife many times to have her call the facility to ask them to help him. The resident's care plan, dated 04/03/17 included a plan for impaired skin integrity due to his psoriasis, Moisture Associated Skin Damage (MASD), and history of pressure ulcers. The interventions were: - Monitor skin for signs/symptoms of skin breakdown i.e. - Observe skin condition with ADL care daily and report abnormalities - Skin check per policy - Weekly skin assessment by license nurse - Weekly wound assessment The facility's policy, NSG236 Skin Integrity Management Effective date 07/01/01, Revision date 11/28/16, directed the staff to continually observe and monitor for skin changes and implement revisions to the plan of care. The purpose, to provide safe and effective care to prevent the occurrence of pressure ulcers and promote healing of all wounds The facility's policy,OPS300 Abuse Prohibition, effective date 06/01/96 Revision date 04/07/17, stated all employees would be trained ongoing to prevent abuse. The facility reported the resident's allegations concerning NA #96 to the Nurse Aide Program at OHFLAC on 04/26/18. These findings were determined to constitute immediate jeopardy to Resident #119. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC) at 1:25 PM on 04/25/18, and preparation of a written statement, the Administrator and Director of Nursing were notified of the Immediate Jeopardy. The facility provided an acceptable at 4:17 PM on 04/25/18. After verifying implementation of the plan of correction, the immediate jeopardy was abated at 5:26 PM on 04/25/18. No deficient practice remained for this requirement after removal of the immediate jeopardy. The Facility's Plan of Correction: On 04/25/18 The RN wound nurse evaluated Resident #119's skin at 3:50 PM, a pain assessment was conducted by RN wound nurse at 3:50 and a Social Worker (SW)/designee will interview the resident on 04/25/18 by 5 PM, to address alleged psychological harm with corrective action upon discovery. The physician was notified of changes at 3:50 PM, by RN wound nurse. On 04/25/18 the center SW reported the allegation of neglect to the appropriate state agencies at 10:44 AM. All residents of the facility have the potential to be affected. The DON/designees will begin to conduct observation of all residents' skin on 04/25/18 with corrective action upon discovery. SW/designees will begin to interview all interview able residents on 04/25/18 to ensure that incontinence care and pain are addressed timely and that residents have not experienced any psychologic harm as evidenced by lack of verbalized fear and be completed by 04/25/18 with corrective action upon discovery. The DON/designees will begin observations of non-interview able residents' skin sweeps on 04/04/25/18 and completed by 04/26/18, including completion of the non-interview able pain evaluation with corrective action upon discovery. The Nurse Practice Educator (NPE)/designee will re-educate all licensed staff on accurate completion and documentation of the weekly skin checks to monitor the patients and his/her wound's response to treatments and interventions beginning on 04/25/18 and all center staff will be re-educated to ensure all center residents are free from neglect, including pain and psychological harm, respond to residents in a timely manner with a post-test to validate understanding beginning 04/25/18. Staff not available during this timeframe will be provided re-education including post-test by the NPE/designee, upon return to work. New hires will be provided education and post-tests during orientation by the NPE/designee. The Unit Managers (UMS)/designee will conduct observation of weekly skin checks, timely response of continence care, pain monitor flow sheets daily for two weeks across all shifts including weekends, then three times a week for two weeks then randomly thereafter to ensure that weekly skin checks are accurate, incontinence care is provided in a timely manner to avoid skin breakdown, and residents pain is addressed based on daily MAR pain evaluation. The SW/designee will conduct sixteen (16) random interviews daily for two weeks across all shifts including weekends, then three times a week for two weeks then randomly thereafter to ensure that residents do not experience any neglect or psychological harm. Trends identified will be reported by the DON monthly to the Quality Improvement Committee (QIC) for any additional follow up and/or in-servicing until the issue is resolved and randomly thereafter as determined by the QIC.

Based on observation, resident interview, staff interview, family interview and record review, the facility failed to ensure nursing staff had the knowledge, skills, and abilities to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. A deficient practice was cited at immediate jeopardy for the care area of Freedom from Abuse, Neglect and Exploitation (F 600). A deficient practice was cited at immediate jeopardy for the care area of Infection Control (F 880). Harm was cited in the care areas of Quality of Care (F 684, F 686 and F 688). A deficient practice was also cited at F 677. This practice had the potential to affect more than a limited number of residents. Facility census: 156. a) Resident #119 - Free from Abuse and Neglect The facility failed to provide timely incontinence care to Resident #119. The resident also tearfully reported being verbally abused by a nurse aide because he had called the nurses' station for help after no one responded to his call bell for thirty (30) minutes. The lack of incontinence care and the verbal abuse caused the resident to experience pain, skin breakdown, and psychological harm. Until the surveyor identified the resident's problems and intervened, staff were not aware of the seriousness of his condition. These findings were determined to constitute immediate jeopardy to Resident #119. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC) at 1:25 PM on 04/25/18, and preparation of a written statement, the Administrator and Director of Nursing were notified of the Immediate Jeopardy. The facility provided an acceptable at 4:17 PM on 04/25/18. After verifying implementation of the plan of correction, the immediate jeopardy was abated at 5:26 PM on 04/25/18. No deficient practice remained for this requirement after removal of the immediate jeopardy. This affected one (1) of seven (7) residents reviewed for activities of daily living. During the initial screening for the Long Term Care Survey Process, an interview on 04/23/18 at 11:37 AM, Resident #119 stated he had a pressure ulcer on his buttock from sitting in urine for 30 minutes or longer. He went on to explain he could not walk, that he tried to use a urinal, but sometimes did not get all of the urine in the urinal. Medical record review found his [DIAGNOSES REDACTED].>- muscle weakness - heart failure - Retention of urine - Type 2 Diabetes underlying condition with hyperosmolarity - Chronic [MEDICAL CONDITIONS] - Obesity - History of pressure ulcers on the right heel and penis According to his minimum data set assessment (MDS) with an assessment reference date (ARD) of ____, his Brief Interview for Mental Status Score (BIMS) was 15, indicating he was cognitively intact. Review of his medical records found no mention of current pressure ulcers. Skin Check Performed Sheets dated from 01/27/18 to 04/23/18 documented the following: - 01/27/18- No Skin Injury/Wounds by Licensed Practical Nurse (LPN) #172 - 02/04/18 -No Skin Injury/Wounds by LPN #92 - 02/10/18- No Skin Injury/Wounds by LPN #172 - 02/17/18- No Skin Injury/Wounds by LPN #92 - 02/24/18- No Skin Injury/Wounds by LPN #172 - 03/03/18- No Skin Injury/Wounds by LPN #92 - 03/10/18- No Skin Injury/Wounds by LPN #172 - 03/17/18 -Yes Skin Injury/Wounds identified No New Skin Injury/Wounds Type of Skin Injury/Wounds Moisture Associated Skin Damage by Registered Nurse (RN) #4 - 03/24/18- No Skin Injury/Wounds by LPN #172 - 04/02/18- No Skin Injury/Wounds by RN #4 - 04/07/18- No Skin Injury/Wounds by LPN #33 - 04/23/18 -No Skin Injury/Wounds by LPN #92 On 04/25/18 at 9:15 AM, Wound Care Nurse #120 agreed to do a complete skin assessment with the surveyor present. On entering the room, Resident #119 was emotional and tearful saying that he was, chewed out, by Nurse Aide #96 for calling the nurses' station with his cell phone. He stated that she told him to only use his call light that was what it was for and not to call the nurses' station again. He said NA #96 told him that he was not the only one on this floor and he just needed to wait his turn. He said he responded by telling her he used the call light and had been waiting for more than 30 minutes before he called the nurses' station with his cell phone because his skin was on fire from sitting in urine. Resident #119 told this to the surveyor, Wound Care Nurse #120, and Nurse Aide #84. With the resident's permission, Wound Care Nurse #120 pulled the sheets back revealing a very large red excoriation on his upper outer thighs. Further investigation found areas of broken skin under his scrotum and coccyx. The resident's tee shirt was saturated with urine up his back and had small amount of stool on the bottom. The resident said NA #96 had changed him, therefore the nurse aide left him with a soiled shirt. Wound Care Nurse #120 removed the resident's tee shirt. When the nurse asked how long his skin had been in this condition, the resident replied it had been a year - that it started after being on this floor for a week. The complete skin audit by Wound Care Nurse #120 found: - 1. Pressure Ulcer Stage II on Coccyx - 2. Pressure Ulcer Stage II on right ear - 3. Excoriated areas bilateral groin, under both breast, bilateral abdominal folds, bilateral upper outer thighs and bilateral calf's. - 4. Reddened area to the right great toe, second and third toes, right heel. During an interview on 04/25/18 at 9:35 AM, Wound Care Nurse #120 stated that he was, Just mortified by what was just discovered, referring to the condition of Resident #119's skin. He went on to say he had no excuse and they had failed this resident. On 04/25/18 at 9:45 AM, the DoN was informed of the findings for Resident #119. She said she was already aware and was working on a plan of correction. On 04/25/18 at 1:10 PM, Resident #119 said that he was still upset over the NA #96 fussing at him that morning and it was not the first time he had had to wait for over 30 minutes for assistance. He went on to say he had called his wife many times to have her call the facility to ask them to help him. The resident's care plan, dated 04/03/17 included a plan for impaired skin integrity due to his psoriasis, Moisture Associated Skin Damage (MASD), and history of pressure ulcers. The interventions were: - Monitor skin for signs/symptoms of skin breakdown i.e. - Observe skin condition with ADL care daily and report abnormalities - Skin check per policy - Weekly skin assessment by license nurse - Weekly wound assessment The facility's policy, NSG236 Skin Integrity Management Effective date 07/01/01, Revision date 11/28/16, directed the staff to continually observe and monitor for skin changes and implement revisions to the plan of care. The purpose, to provide safe and effective care to prevent the occurrence of pressure ulcers and promote healing of all wounds The facility's policy,OPS300 Abuse Prohibition, effective date 06/01/96 Revision date 04/07/17, stated all employees would be trained ongoing to prevent abuse. The facility reported the resident's allegations concerning NA #96 to the Nurse Aide Program at OHFLAC on 04/26/18. These findings were determined to constitute immediate jeopardy to Resident #119. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC) at 1:25 PM on 04/25/18, and preparation of a written statement, the Administrator and Director of Nursing were notified of the Immediate Jeopardy. The facility provided an acceptable at 4:17 PM on 04/25/18. After verifying implementation of the plan of correction, the immediate jeopardy was abated at 5:26 PM on 04/25/18. No deficient practice remained for this requirement after removal of the immediate jeopardy. The Facility's Plan of Correction: On 04/25/18 The RN wound nurse evaluated Resident #119's skin at 3:50 PM, a pain assessment was conducted by RN wound nurse at 3:50 and a Social Worker (SW)/designee will interview the resident on 04/25/18 by 5 PM, to address alleged psychological harm with corrective action upon discovery. The physician was notified of changes at 3:50 PM, by RN wound nurse. On 04/25/18 the center SW reported the allegation of neglect to the appropriate state agencies at 10:44 AM. All residents of the facility have the potential to be affected. The DON/designees will begin to conduct observation of all residents' skin on 04/25/18 with corrective action upon discovery. SW/designees will begin to interview all interview able residents on 04/25/18 to ensure that incontinence care and pain are addressed timely and that residents have not experienced any psychologic harm as evidenced by lack of verbalized fear and be completed by 04/25/18 with corrective action upon discovery. The DON/designees will begin observations of non-interview able residents' skin sweeps on 04/04/25/18 and completed by 04/26/18, including completion of the non-interview able pain evaluation with corrective action upon discovery. The Nurse Practice Educator (NPE)/designee will re-educate all licensed staff on accurate completion and documentation of the weekly skin checks to monitor the patients and his/her wound's response to treatments and interventions beginning on 04/25/18 and all center staff will be re-educated to ensure all center residents are free from neglect, including pain and psychological harm, respond to residents in a timely manner with a post-test to validate understanding beginning 04/25/18. Staff not available during this timeframe will be provided re-education including post-test by the NPE/designee, upon return to work. New hires will be provided education and post-tests during orientation by the NPE/designee. The Unit Managers (UMS)/designee will conduct observation of weekly skin checks, timely response of continence care, pain monitor flow sheets daily for two weeks across all shifts including weekends, then three times a week for two weeks then randomly thereafter to ensure that weekly skin checks are accurate, incontinence care is provided in a timely manner to avoid skin breakdown, and residents pain is addressed based on daily MAR pain evaluation. The SW/designee will conduct sixteen (16) random interviews daily for two weeks across all shifts including weekends, then three times a week for two weeks then randomly thereafter to ensure that residents do not experience any neglect or psychological harm. Trends identified will be reported by the DON monthly to the Quality Improvement Committee (QIC) for any additional follow up and/or in-servicing until the issue is resolved and randomly thereafter as determined by the QIC. b) Activities of Daily Living Provided to Dependent Residents The failure to ensure dependent residents received needed care and services resulted in actual harm for Resident #26. Resident #26 did not receive care needed care for her hands, resulting in a Stage II pressure area on her palm and pain when attempts were made to open her hand. The facility's failure to ensure Resident #119 received needed skin care and prompt incontinence care were determined to result in actual harm to this resident as he developed pressure ulcers and painful excoriation. Resident #80 needed hygienic measures for hand contractures. Resident identifiers: #80, #26, and #119. Facility census: 156. 1) Resident #26 Observation of the resident at 4:45 p.m. on 04/23/18, found the resident's left and right hands appeared contracted. The resident had no splinting devices in use. Review of the resident's current care plan found the following focus/problem: - Resident requires assistance with ADL's (activities of daily living) due to limited mobility. The goal associated with the problem: - Residents/Patients ADL care needs will be anticipated and met throughout the next review period. Interventions included: - Monitor for decline in ADL function. Refer to rehabilitation therapy and decline in ADL's is noted. Provide resident extensive assist for bed mobility, dressing, eating, personal hygiene, and grooming. While investigating to determine why the resident had possible contractures without splinting devices the following observations were made: - Observation of the resident at 1:44 p.m. on 04/25/18, with OT #171 revealed, OT #171 was able to open the resident's right hand with without difficulty. When opened, a sour odor, coming from the resident's right hand was evident. OT #171 said she had sinuses and could not smell the odor. When OT #171 attempted to open the resident's left hand, a strong putrid, foul smelling, sour odor, emanated from the hand. OT #171 acknowledged she could smell the odor coming from the left hand. OT #171 said she would get staff to clean the resident's hands. OT #171 was unable to fully extend all the fingers of the resident's left hand. The ring finger was pressed into the palm of the resident's hand. It was evident the finger nailwas cutting into the palm of the resident's hand. OT #171 said, She was never like this when we finished with therapy services in January. When OT #171, discarded her gloves in the trash can in the corner of the resident's room, the foul odor from the gloves could be smelled coming out of the trash can. Throughout the observation, the resident said, Ouch, that hurts, that hurts, when OT #171 was attempting to work with the resident's left hand. The resident also said, I need my fingernails cut, the doctor said so. The resident nails were long jagged and unclean. These observations were discussed with the director of nursing (DON) at 2:00 p.m. on 04/25/18. The DON said she would have a nurse soak the resident's hand in warm water, assess the condition of the hands and cut the fingernails. At 2:15 p.m. on 04/25/18, Licensed Practical Nurse (LPN) #26 was observed cleaning the resident's hands and cutting the fingernails. LPN #26 acknowledged the resident had a foul smelling odor coming from both hands. LPN #26 said she thought she could see a, break in the skin, on the palm of the left hand. She said, I won't know for sure until I soak the hand and get it to open a little more. At 3:15 p.m. on 04/25/18, the director of rehabilitation services, Employee #170 said the resident was screened for services on 04/19/18. E #170 said, When we screen a resident we can't touch them. If the patient can't tell us what is wrong or the staff don't tell us we don't know. She said the resident didn't want any therapy but did agree to a speech evaluation. E#170 said staff would not have looked at the resident's hands. At 3:17 p.m. on 4/25/18, the information received from E#170 was discussed with the DON. The DON said she was unaware a therapist could not touch a resident during a screen. At 8:10 a.m. on 04/26/18, observation with the DON found the DON confirmed the resident had a Stage II pressure area on the left hand, just under the ring finger on the palm of left hand. The DON acknowledged the resident still had a slight sour odor coming from the left hand. At 8:35 a.m. on 004/26/18, the DON said, I am taking care of this, calling the doctor, the residents family and will get an order for [REDACTED]. The DON acknowledged staff had not been cleaning the resident's hands as needed to prevent the odor. The DON said the skin check, completed by the nursing staff on 04/20/18, should have caught the problem. The DON was unable to provide any information to support the facility was aware of the foul odor of the resident's hands, the left hand contracture, or the development of a Stage II pressure area on the palm of the resident's left hand, prior to surveyor intervention. The failure to provide extensive assistance for personal hygiene, (ADL care and cleaning) of the residents hands lead to the foul odor coming from both the left and right hands. Had ADL care been provided, the facility may have recognized the inability of the resident to voluntarily open both the left and right hands. Had the facility addressed this decline, the contracture of the left hand may have been prevented. The failure to address the resident's contracture of the left hand lead contributed to the development of a Stage II pressure ulcer to the left hand. This was determined to constitute actual harm to this resident. 2) Resident #119 During the screening for the initial pool of the Long-Term Care Survey Process, an interview on 04/23/18 at 11:37 AM with Resident #119 revealed he had a pressure ulcer on his lower buttock from sitting in urine for 30 minutes or longer. He went on to explain he could not walk, and tried to use a urinal, but sometimes did not get all the urine in the urinal. He stated there was not enough staff last night - one aide was with two (2) nurse aides in training. According to the resident, it takes more than an hour for staff to answer a call light. He said he had been told his aide was on break, and the aides also told him they were short staffed. This was mostly on the 3:00 PM to 11:00 PM or the 11:00 PM to 7:00 AM shifts. On 04/25/18 at 9:15 AM, Resident #119 was emotional and tearful saying that he was chewed out by the Nurse Aide #96 for calling the nurses' station with his cell phone. He stated she told him to only use his call light, that was what it was for, and not to call the nurses' station again. He said, NA #96 told him that he was not the only one on this floor and he just needed to wait his turn. He said he responded by telling her he used the call light and had been waiting for more than 30 minutes before he called the nurses' station with his cell phone, because his skin was on fire from sitting in urine. The resident told this to the surveyor, Wound Care Nurse #120, and Nurse Aide #84. On 04/25/18 at 9:15 AM, Wound Care Nurse #120 agreed to do a complete skin assessment with the surveyor present. A complete skin audit by Wound Care Nurse #120 found: - 1. Pressure Ulcer Stage II on Coccyx - 2. Pressure Ulcer Stage II on right ear - 3. Excoriated areas bilateral groin, under both breast, bilateral abdominal folds, bilateral upper outer thighs and bilateral calf's. - 4. Reddened area to the right great toe, second and third toes, right heel. The failure of the facility to ensure needed skin care and prompt incontinence care were determined to result in actual harm to this resident. During an interview on 04/25/18 at 9:45 AM, when informed of findings, the DoN stated she had heard from Wound Care Nurse #120 and was addressing the problem. On 04/25/18 at 1:10 PM, Resident #119 said that he was still upset over the NA #96 fussing at him that morning and it was not the first time he has had to wait for over 30 minutes for assistance. He went on to say he has called his wife many times to have her call the facility to ask them to help him. 3) Resident #80 Observation on 04/23/18 at 3:40 p.m. found this resident lying in bed. He had contractures of both hands. There were no splints, palm guards, or any type of device in place to either hand. Observations on 04/24/18 at 10:30 a.m., again found he had no splints, palm guards, rolled washcloths or any devices in either hand. He held both hands firmly closed. At 12:15 p.m. on 04/24/18, while accompanied by Registered Nurse Employee #13 (E#13), a white washcloth was found placed partially in his left hand, and a thin, smaller, yellow-colored cloth was was found placed partially in his right hand. When asked whether these cloths were placed in his hands later than 10:45 a.m. that morning, E#13 replied in the affirmative and said she had placed them. On 04/24/18 at 12:15 p.m., E#13 removed the cloths in preparation for inspection of the palms of both hands. When the nurse removed the cloths from his hands, a foul smell was immediately noted. When asked if that foul odor came from the cloths having been placed in his hands, E#13 stated I can't put my nose on them to smell them. E#13 tried to move the contracted fingers so the palms could be visualized. His fingers were drawn down tightly, which made visualization of the palms inadequate. She moved the right thumb about one-quarter of an inch outward, which then allowed visualization of a dry, reddened area on the skin of the fourth finger of the right hand. The thumbnail of the right hand lay directly on top of, and pressing against, the reddened area of the fourth finger beneath it. The right thumbnail was smooth, but long, protruding beyond the flesh at the tip of the thumb a quarter of an inch. It needed trimmed. At 3:15 p.m. on 04/24/18, Occupational Therapist Employee #171 and wound nurse/registered nurse E#120 came to the resident's bed. A white wash cloth and a thinner, yellow cloth lay on his chest. The palms could only slightly be visualized. E#120 said they were aware of the reddened area to the right fourth finger and were monitoring and treating it. He said the right thumbnail needed trimmed. Review of a grievance on 04/24/18 at 4:00 p.m. found one from the daughter of Resident #80 dated 02/19/18. It stated Daughter concerned resident's hands are not being cleaned and nails aren't being clipped as often as they should be. The corrective action from Unit 3 Nursing Staff stated Ordered hands to be cleaned daily and nails trimmed every Tuesday and Friday. Review of the (MONTH) Medication Administration Record [REDACTED]. This was a one (1) week audit. The (MONTH) MAR indicated [REDACTED]. Staff initialed its completion on 03/06/18 and 03/09/18. The space for 03/13/18 was left blank. This, too, was on the MAR for one (1) week. Review of the resident's care plan on 04/24/18 at 4:00 p.m., found an area of focus for the resident being dependent for ADL care as evidenced by multiple contractures. A goal included that he would be clean, dry and odor free through next review. The care plan was not fully developed to include cleaning his hands daily and/or how to accomplish that task, or anything about nail trimming. Observation on 04/25/18 at 2:25 p.m., accompanied by licensed nurse Employee #80 (E#80) found no cloths, palm guards or any devices in either hand. When asked why there was no padding or cloth between the thumbnail and the fourth finger of the right hand to reduce pressure, she threaded the yellow cloth into the resident's right hand. She ensured it padded the skin between the right thumbnail and the reddened area to the fourth finger beneath it. The nurse agreed the right thumbnail was too long. She said she had some clippers and would cut and trim that offending right thumbnail. The nurse also placed a washcloth in the palm of the left hand. During an interview on 04/25/18 at 6:00 p.m. , the director of nursing said there should not have been an odor from the palms of his hands as it was possible for staff to clean his hands. She was informed that the nurse on 04/24/18 at 3:15 p.m. stated his right thumbnail was too long, and that they were monitoring and treating the reddened skin area to the right fourth finger upon which the right thumb and thumbnail rested. She was also informed that the following day on 04/25/18 at 2:25 p.m. the right thumbnail was still long and in need of trimming. The nurse on duty at 2:25 p.m. on 04/25/18 said she had clippers and would trim the thumb nail right away. A copy of the grievance form dated 02/19/18 conveyed the resident's daughter's concern that his hands were not cleaned and his nails not clipped as often as they should be. The DON acknowledged the grievance. No further information was provided prior to exit. On 04/26/18 at approximately 9:30 a.m., these findings were discussed with the administrator. No further information was provided by the facility prior to exit. c) Quality of Care 1) Resident #147 Resident #147 did not receive insulin as directed by the physician which lead to harm due to critically elevated blood glucose levels, high sodium levels, and acute kidney injury. Additionally, there was no evidence of an assessment of the resident's mental and physical status when his blood sugars were over 600. Furthermore, the resident's antibiotic was stopped prior to completion of the course ordered by the physician, but there was no evidence the physician had ordered it discontinued. Resident identifier: #147. Facility census: 156. An interview with the resident and his daughter at 11:19 a.m. on 04/23/18, found the daughter was very worried about the medical condition of her father. The daughter said her father had been very confused, his blood sugars were high, he had an incontinent episode, and he had a cough. She said her father was recently diagnosed with [REDACTED]. She was fearful he would die if something was not done. She said she talked to someone of Saturday, a nurse she thought, who said she would have to wait until Monday to see the doctor. She said the facility did get a chest x-ray, but she did not think this would tell them if he was having other problems. She believed her father needed to have some blood work and hoping that was going to happen that day. Record review found a [AGE] year-old male resident admitted to the facility on [DATE]. His hospital discharge summary noted the resident was hosptalized on [DATE]. He was treated for [REDACTED]. ANCA (associated small-vessel vasculitis) are autoantibodies produced by a person's immune system that mistakenly attack proteins within the person's [DIAGNOSES REDACTED]s (white blood cell types). The most common subsets of ANCA are those that target the proteins myeloperoxidase (MPO) and proteinase.) The resident was discharged from the hospital to the nursing home on 03/28/18. Review of the resident's medical record found he was seen by the family nurse practitioner (FNP) on Saturday, 04/20/18 for a change in condition. The FNP noted, Chief Complaint / Nature of Presenting Problem: [DIAGNOSES REDACTED], family concerned regarding cough History of Present Illness: The patient is a [AGE] year old male with known history of [MEDICAL CONDITION] and confusion. Patient reports feeling well. Does seem more lethargic today. Daughter reports patient has been coughing and she is worried he has pneumonia as 'this is how it starts, when he looks, lost,' nurse at bedside check patient's blood glucose for noon and BG (blood glucose) was 50. Patient did eat breakfast this morning staff relates. The plan for treatment was: 1. [MEDICATION NAME] decreased to 5 units TID (3 times a day) with meals 2. [MEDICATION NAME] decreased to 20 units QHS (every hour of sleep/bedtime) 3. patient was given lunch, and order to recheck blood glucose one hour after lunch, to notify provider if remains low after a meal orders discussed with nursing A handwritten physician's orders [REDACTED]. Check BMG (a small protein and is readily reabsorbed by kidneys with normal function) 1 hour after lunch due to [DIAGNOSES REDACTED] decrease [MEDICATION NAME] to 20 units QHS decrease insulin [MEDICATION NAME] to 5 units TID (3 times a day) with meals for [DIAGNOSES REDACTED]. Review of the resident's Medication Administration Record [REDACTED] -- The [MEDICATION NAME] was not decreased to 20 units as directed by the physician on 04/20/18. -- The [MEDICATION NAME] was discontinued and was not given at all, until Monday 04/23/18. The resident's blood glucose readings were: - On 04/21/18: BG (Blood Glucose) was 312 at 7:30 a.m. BG 171 at 11:30 a.m. BG 357 at 4:30 p.m. - On 04/22/18: BG 384 at 7:30 a.m. BG 396 at 11:30 a.m. BG 253 at 4:30 p.m. On 04/23/18 at 6:30 a.m., the resident's blood glucose was so high, the facility was unable to obtain a reading. The nurse's note, dated 04/23/18 at 6:37, noted the resident's blood glucose level was over 600. The resident's physician was contacted and ordered, Humalog 10 units now. Recheck glucose in 1 hours. If glucose is higher than 400 repeat 1 dose. At 7:30 a.m. on 04/23/18, the MAR indicated [REDACTED]. Another 10 units of Humalog was administered. At 8:30 a.m. on 04/23/18, the resident's blood glucose was still 511. At 9:40 a.m. on 04/23/18 another 15 units of Humalog was administered, according to the MAR. Nursing staff contacted the physician for this order. A nursing note written at 12:06 a.m. on 04/23/18, noted the physician was contacted and another 20 units of [MEDICATION NAME] was given and the physician said to give the [MEDICATION NAME] that is due tonight. The MAR indicated [REDACTED] There were no nursing notes describing the resident's condition when his blood glucose was above 600; such as was the resident level of consciousness affected, was he thirsty, tired, was his coordination affected, etc. The resident was seen by the physician on 04/23/18 at 7:35 p.m. The plan ordered by the physician: Stat (immediately) labs came back. WBC (white blood cell count) is normal. But BUN/CR (blood urea nitrogen/creatinine ratio) significantly increased from prior. K (potassium) is 5.7. Patient in AKI (acute kidney injury), ordered IVF (intravenous fluids), hold [MEDICATION NAME] and [MEDICATION NAME], give [MEDICATION NAME] for [MEDICAL CONDITION] (high potassium). Recheck BMP (basic metabolic panel) in morning, the low sodium on BMP is due to high BG of over 700. The BG has been checked since then and it is down to 200's no longer in 700's. At 8:40 a.m. on 04/25/18, the director of nursing (DON) was interviewed regarding Resident #126. Before the interview began, the DON said, I already know a medication error was made regarding the physician's orders [REDACTED]. The DON verified the [MEDICATION NAME] was to be decreased to 20 units due to the resident's low blood glucose level of 50 obtained on 04/20/18. She said the new order was transcribed to the MAR, but was then discontinued. The resident never received any [MEDICATION NAME] and the resident's blood glucose levels were above 600, 3 days after the medication was stopped when it should have been reduced. The DON verified the blood glucose level was not obtained after the [MEDICATION NAME] was administered at 11:00 a.m. on 04/24/18. The DON said she had already disciplined the staff involved in the medication errors. The DON confirmed the medication error resulted in treatments that could have been prevented if staff had followed the physician's orders [REDACTED]. The failure to administer insulin as ordered by the physician and to monitor the resident's blood glucose when indicated resulted in actual harm to this resident. On 04/02/18 the physician ordered [MEDICATION NAME] 1 gram IM (intramuscular) daily for the next 4 days, pending the results of the urinalysis. Review of the resident's Medication Administration Record [REDACTED]. There was no explanation why the medication was discontinued, and no evidence the physician was contacted and approved the discontinuation. At 9:21 a.m. on 04/25/18, the DON said the results of the urinalysis showed the resident did not have a urinary tract infection. She said the nursing staff should have documented the physician was contacted and the staff should have obtained an order to discontinue the [MEDICATION NAME]. d) Pressure Ulcers Resident #119, a depende (TRUNCATED)

Based on observations, resident interviews, and staff interview, the facility failed to provide activities of daily living (ADL) care for three (3) of nine (9) residents reviewed for ADL care. The failure to ensure dependent residents received needed care and services resulted in actual harm for Resident #26. Resident #26 did not receive care needed care for her hands, resulting in a Stage II pressure area on her palm and pain when attempts were made to open her hand. The facility's failure to ensure Resident #119 received needed skin care and prompt incontinence care were determined to result in actual harm to this resident as he developed pressure ulcers and painful excoriation. Resident #80 needed hygienic measures for hand contractures. Resident identifiers: #80, #26, and #119. Facility census: 156. Findings included: a) Resident #26 Observation of the resident at 4:45 p.m. on 04/23/18, found the resident's left and right hands appeared contracted. The resident had no splinting devices in use. Review of the resident's current care plan found the following focus/problem: - Resident requires assistance with ADL's (activities of daily living) due to limited mobility. The goal associated with the problem: - Residents/Patients ADL care needs will be anticipated and met throughout the next review period. Interventions included: - Monitor for decline in ADL function. Refer to rehabilitation therapy and decline in ADL's is noted. Provide resident extensive assist for bed mobility, dressing, eating, personal hygiene, and grooming. While investigating to determine why the resident had possible contractures without splinting devices the following observations were made: - Observation of the resident at 1:44 p.m. on 04/25/18, with OT #171 revealed, OT #171 was able to open the resident's right hand with without difficulty. When opened, a sour odor, coming from the resident's right hand was evident. OT #171 said she had sinuses and could not smell the odor. When OT #171 attempted to open the resident's left hand, a strong putrid, foul smelling, sour odor, emanated from the hand. OT #171 acknowledged she could smell the odor coming from the left hand. OT #171 said she would get staff to clean the resident's hands. OT #171 was unable to fully extend all the fingers of the resident's left hand. The ring finger was pressed into the palm of the resident's hand. It was evident the finger nailwas cutting into the palm of the resident's hand. OT #171 said, She was never like this when we finished with therapy services in January. When OT #171, discarded her gloves in the trash can in the corner of the resident's room, the foul odor from the gloves could be smelled coming out of the trash can. Throughout the observation, the resident said, Ouch, that hurts, that hurts, when OT #171 was attempting to work with the resident's left hand. The resident also said, I need my fingernails cut, the doctor said so. The resident nails were long jagged and unclean. These observations were discussed with the director of nursing (DON) at 2:00 p.m. on 04/25/18. The DON said she would have a nurse soak the resident's hand in warm water, assess the condition of the hands and cut the fingernails. At 2:15 p.m. on 04/25/18, Licensed Practical Nurse (LPN) #26 was observed cleaning the resident's hands and cutting the fingernails. LPN #26 acknowledged the resident had a foul smelling odor coming from both hands. LPN #26 said she thought she could see a, break in the skin, on the palm of the left hand. She said, I won't know for sure until I soak the hand and get it to open a little more. At 3:15 p.m. on 04/25/18, the director of rehabilitation services, Employee #170 said the resident was screened for services on 04/19/18. E #170 said, When we screen a resident we can't touch them. If the patient can't tell us what is wrong or the staff don't tell us we don't know. She said the resident didn't want any therapy but did agree to a speech evaluation. E#170 said staff would not have looked at the resident's hands. At 3:17 p.m. on 4/25/18, the information received from E#170 was discussed with the DON. The DON said she was unaware a therapist could not touch a resident during a screen. At 8:10 a.m. on 04/26/18, observation with the DON found the DON confirmed the resident had a Stage II pressure area on the left hand, just under the ring finger on the palm of left hand. The DON acknowledged the resident still had a slight sour odor coming from the left hand. At 8:35 a.m. on 004/26/18, the DON said, I am taking care of this, calling the doctor, the residents family and will get an order for [REDACTED]. The DON acknowledged staff had not been cleaning the resident's hands as needed to prevent the odor. The DON said the skin check, completed by the nursing staff on 04/20/18, should have caught the problem. The DON was unable to provide any information to support the facility was aware of the foul odor of the resident's hands, the left hand contracture, or the development of a Stage II pressure area on the palm of the resident's left hand, prior to surveyor intervention. The failure to provide extensive assistance for personal hygiene, (ADL care and cleaning) of the residents hands lead to the foul odor coming from both the left and right hands. Had ADL care been provided, the facility may have recognized the inability of the resident to voluntarily open both the left and right hands. Had the facility addressed this decline, the contracture of the left hand may have been prevented. The failure to address the resident's contracture of the left hand lead contributed to the development of a Stage II pressure ulcer to the left hand. This was determined to constitute actual harm to this resident. b) Resident #119 During the screening for the initial pool of the Long-Term Care Survey Process, an interview on 04/23/18 at 11:37 AM with Resident #119 revealed he had a pressure ulcer on his lower buttock from sitting in urine for 30 minutes or longer. He went on to explain he could not walk, and tried to use a urinal, but sometimes did not get all the urine in the urinal. He stated there was not enough staff last night - one aide was with two (2) nurse aides in training. According to the resident, it takes more than an hour for staff to answer a call light. He said he had been told his aide was on break, and the aides also told him they were short staffed. This was mostly on the 3:00 PM to 11:00 PM or the 11:00 PM to 7:00 AM shifts. On 04/25/18 at 9:15 AM, Resident #119 was emotional and tearful saying that he was chewed out by the Nurse Aide #96 for calling the nurses' station with his cell phone. He stated she told him to only use his call light, that was what it was for, and not to call the nurses' station again. He said, NA #96 told him that he was not the only one on this floor and he just needed to wait his turn. He said he responded by telling her he used the call light and had been waiting for more than 30 minutes before he called the nurses' station with his cell phone, because his skin was on fire from sitting in urine. The resident told this to the surveyor, Wound Care Nurse #120, and Nurse Aide #84. On 04/25/18 at 9:15 AM, Wound Care Nurse #120 agreed to do a complete skin assessment with the surveyor present. A complete skin audit by Wound Care Nurse #120 found: - 1. Pressure Ulcer Stage II on Coccyx - 2. Pressure Ulcer Stage II on right ear - 3. Excoriated areas bilateral groin, under both breast, bilateral abdominal folds, bilateral upper outer thighs and bilateral calf's. - 4. Reddened area to the right great toe, second and third toes, right heel. The failure of the facility to ensure needed skin care and prompt incontinence care were determined to result in actual harm to this resident. During an interview on 04/25/18 at 9:45 AM, when informed of findings, the DoN stated she had heard from Wound Care Nurse #120 and was addressing the problem. On 04/25/18 at 1:10 PM, Resident #119 said that he was still upset over the NA #96 fussing at him that morning and it was not the first time he has had to wait for over 30 minutes for assistance. He went on to say he has called his wife many times to have her call the facility to ask them to help him. c) Resident #80 Observation on 04/23/18 at 3:40 p.m. found this resident lying in bed. He had contractures of both hands. There were no splints, palm guards, or any type of device in place to either hand. Observations on 04/24/18 at 10:30 a.m., again found he had no splints, palm guards, rolled washcloths or any devices in either hand. He held both hands firmly closed. At 12:15 p.m. on 04/24/18, while accompanied by Registered Nurse Employee #13 (E#13), a white washcloth was found placed partially in his left hand, and a thin, smaller, yellow-colored cloth was was found placed partially in his right hand. When asked whether these cloths were placed in his hands later than 10:45 a.m. that morning, E#13 replied in the affirmative and said she had placed them. On 04/24/18 at 12:15 p.m., E#13 removed the cloths in preparation for inspection of the palms of both hands. When the nurse removed the cloths from his hands, a foul smell was immediately noted. When asked if that foul odor came from the cloths having been placed in his hands, E#13 stated I can't put my nose on them to smell them. E#13 tried to move the contracted fingers so the palms could be visualized. His fingers were drawn down tightly, which made visualization of the palms inadequate. She moved the right thumb about one-quarter of an inch outward, which then allowed visualization of a dry, reddened area on the skin of the fourth finger of the right hand. The thumbnail of the right hand lay directly on top of, and pressing against, the reddened area of the fourth finger beneath it. The right thumbnail was smooth, but long, protruding beyond the flesh at the tip of the thumb a quarter of an inch. It needed trimmed. At 3:15 p.m. on 04/24/18, Occupational Therapist Employee #171 and wound nurse/registered nurse E#120 came to the resident's bed. A white wash cloth and a thinner, yellow cloth lay on his chest. The palms could only slightly be visualized. E#120 said they were aware of the reddened area to the right fourth finger and were monitoring and treating it. He said the right thumbnail needed trimmed. Review of a grievance on 04/24/18 at 4:00 p.m. found one from the daughter of Resident #80 dated 02/19/18. It stated Daughter concerned resident's hands are not being cleaned and nails aren't being clipped as often as they should be. The corrective action from Unit 3 Nursing Staff stated Ordered hands to be cleaned daily and nails trimmed every Tuesday and Friday. Review of the (MONTH) Medication Administration Record [REDACTED]. This was a one (1) week audit. The (MONTH) MAR indicated [REDACTED]. Staff initialed its completion on 03/06/18 and 03/09/18. The space for 03/13/18 was left blank. This, too, was on the MAR for one (1) week. Review of the resident's care plan on 04/24/18 at 4:00 p.m., found an area of focus for the resident being dependent for ADL care as evidenced by multiple contractures. A goal included that he would be clean, dry and odor free through next review. The care plan was not fully developed to include cleaning his hands daily and/or how to accomplish that task, or anything about nail trimming. Observation on 04/25/18 at 2:25 p.m., accompanied by licensed nurse Employee #80 (E#80) found no cloths, palm guards or any devices in either hand. When asked why there was no padding or cloth between the thumbnail and the fourth finger of the right hand to reduce pressure, she threaded the yellow cloth into the resident's right hand. She ensured it padded the skin between the right thumbnail and the reddened area to the fourth finger beneath it. The nurse agreed the right thumbnail was too long. She said she had some clippers and would cut and trim that offending right thumbnail. The nurse also placed a washcloth in the palm of the left hand. During an interview on 04/25/18 at 6:00 p.m. , the director of nursing said there should not have been an odor from the palms of his hands as it was possible for staff to clean his hands. She was informed that the nurse on 04/24/18 at 3:15 p.m. stated his right thumbnail was too long, and that they were monitoring and treating the reddened skin area to the right fourth finger upon which the right thumb and thumbnail rested. She was also informed that the following day on 04/25/18 at 2:25 p.m. the right thumbnail was still long and in need of trimming. The nurse on duty at 2:25 p.m. on 04/25/18 said she had clippers and would trim the thumb nail right away. A copy of the grievance form dated 02/19/18 conveyed the resident's daughter's concern that his hands were not cleaned and his nails not clipped as often as they should be. The DON acknowledged the grievance. No further information was provided prior to exit. On 04/26/18 at approximately 9:30 a.m., these findings were discussed with the administrator. No further information was provided by the facility prior to exit.

Based on family interview, staff interview, record review, and observation, the facility failed to ensure one (1) of thirty-one (31) residents reviewed receive care and services in accordance with the comprehensive assessment and plan of care. Resident #147 did not receive insulin as directed by the physician which lead to harm due to critically elevated blood glucose levels, high sodium levels, and acute kidney injury. Additionally, there was no evidence of an assessment of the resident's mental and physical status when his blood sugars were over 600. Furthermore, the resident's antibiotic was stopped prior to completion of the course ordered by the physician, but there was no evidence the physician had ordered it discontinued. Resident identifier: #147. Facility census: 156. Findings included: a) Resident #147 1. An interview with the resident and his daughter at 11:19 a.m. on 04/23/18, found the daughter was very worried about the medical condition of her father. The daughter said her father had been very confused, his blood sugars were high, he had an incontinent episode, and he had a cough. She said her father was recently diagnosed with [REDACTED]. She was fearful he would die if something was not done. She said she talked to someone of Saturday, a nurse she thought, who said she would have to wait until Monday to see the doctor. She said the facility did get a chest x-ray, but she did not think this would tell them if he was having other problems. She believed her father needed to have some blood work and hoping that was going to happen that day. Record review found a [AGE] year-old male resident admitted to the facility on [DATE]. His hospital discharge summary noted the resident was hosptalized on [DATE]. He was treated for [REDACTED]. ANCA (associated small-vessel vasculitis) are autoantibodies produced by a person's immune system that mistakenly attack proteins within the person's [DIAGNOSES REDACTED]s (white blood cell types). The most common subsets of ANCA are those that target the proteins myeloperoxidase (MPO) and proteinase.) The resident was discharged from the hospital to the nursing home on 03/28/18. Review of the resident's medical record found he was seen by the family nurse practitioner (FNP) on Saturday, 04/20/18 for a change in condition. The FNP noted, Chief Complaint / Nature of Presenting Problem: [DIAGNOSES REDACTED], family concerned regarding cough History of Present Illness: The patient is a [AGE] year old male with known history of [MEDICAL CONDITION] and confusion. Patient reports feeling well. Does seem more lethargic today. Daughter reports patient has been coughing and she is worried he has pneumonia as 'this is how it starts, when he looks, lost,' nurse at bedside check patient's blood glucose for noon and BG (blood glucose) was 50. Patient did eat breakfast this morning staff relates. The plan for treatment was: 1. [MEDICATION NAME] decreased to 5 units TID (3 times a day) with meals 2. [MEDICATION NAME] decreased to 20 units QHS (every hour of sleep/bedtime) 3. patient was given lunch, and order to recheck blood glucose one hour after lunch, to notify provider if remains low after a meal orders discussed with nursing A handwritten physician's orders [REDACTED]. Check BMG (a small protein and is readily reabsorbed by kidneys with normal function) 1 hour after lunch due to [DIAGNOSES REDACTED] decrease [MEDICATION NAME] to 20 units QHS decrease insulin [MEDICATION NAME] to 5 units TID (3 times a day) with meals for [DIAGNOSES REDACTED]. Review of the resident's Medication Administration Record [REDACTED] -- The [MEDICATION NAME] was not decreased to 20 units as directed by the physician on 04/20/18. -- The [MEDICATION NAME] was discontinued and was not given at all, until Monday 04/23/18. The resident's blood glucose readings were: - On 04/21/18: BG (Blood Glucose) was 312 at 7:30 a.m. BG 171 at 11:30 a.m. BG 357 at 4:30 p.m. - On 04/22/18: BG 384 at 7:30 a.m. BG 396 at 11:30 a.m. BG 253 at 4:30 p.m. On 04/23/18 at 6:30 a.m., the resident's blood glucose was so high, the facility was unable to obtain a reading. The nurse's note, dated 04/23/18 at 6:37, noted the resident's blood glucose level was over 600. The resident's physician was contacted and ordered, Humalog 10 units now. Recheck glucose in 1 hours. If glucose is higher than 400 repeat 1 dose. At 7:30 a.m. on 04/23/18, the MAR indicated [REDACTED]. Another 10 units of Humalog was administered. At 8:30 a.m. on 04/23/18, the resident's blood glucose was still 511. At 9:40 a.m. on 04/23/18 another 15 units of Humalog was administered, according to the MAR. Nursing staff contacted the physician for this order. A nursing note written at 12:06 a.m. on 04/23/18, noted the physician was contacted and another 20 units of [MEDICATION NAME] was given and the physician said to give the [MEDICATION NAME] that is due tonight. The MAR indicated [REDACTED] There were no nursing notes describing the resident's condition when his blood glucose was above 600; such as was the resident level of consciousness affected, was he thirsty, tired, was his coordination affected, etc. The resident was seen by the physician on 04/23/18 at 7:35 p.m. The plan ordered by the physician: Stat (immediately) labs came back. WBC (white blood cell count) is normal. But BUN/CR (blood urea nitrogen/creatinine ratio) significantly increased from prior. K (potassium) is 5.7. Patient in AKI (acute kidney injury), ordered IVF (intravenous fluids), hold [MEDICATION NAME] and [MEDICATION NAME], give [MEDICATION NAME] for [MEDICAL CONDITION] (high potassium). Recheck BMP (basic metabolic panel) in morning, the low sodium on BMP is due to high BG of over 700. The BG has been checked since then and it is down to 200's no longer in 700's. At 8:40 a.m. on 04/25/18, the director of nursing (DON) was interviewed regarding Resident #147. Before the interview began, the DON said, I already know a medication error was made regarding the physician's orders [REDACTED]. The DON verified the [MEDICATION NAME] was to be decreased to 20 units due to the resident's low blood glucose level of 50 obtained on 04/20/18. She said the new order was transcribed to the MAR, but was then discontinued. The resident never received any [MEDICATION NAME] and the resident's blood glucose levels were above 600, 3 days after the medication was stopped when it should have been reduced. The DON verified the blood glucose level was not obtained after the [MEDICATION NAME] was administered at 11:00 a.m. on 04/24/18. The DON said she had already disciplined the staff involved in the medication errors. The DON confirmed the medication error resulted in treatments that could have been prevented if staff had followed the physician's orders [REDACTED]. The failure to administer insulin as ordered by the physician and to monitor the resident's blood glucose when indicated resulted in actual harm to this resident. 2. On 04/02/18 the physician ordered [MEDICATION NAME] 1 gram IM (intramuscular) daily for the next 4 days, pending the results of the urinalysis. Review of the resident's Medication Administration Record [REDACTED]. There was no explanation why the medication was discontinued, and no evidence the physician was contacted and approved the discontinuation. At 9:21 a.m. on 04/25/18, the DON said the results of the urinalysis showed the resident did not have a urinary tract infection. She said the nursing staff should have documented the physician was contacted and the staff should have obtained an order to discontinue the [MEDICATION NAME].

Based on resident interview, record review, staff interview, review of facility policy, and observations, the facility failed to provide appropriate care and services to prevent pressure ulcers and failed to identify pressure ulcers after they developed for two (2) of five (5) residents reviewed for the care area of pressure ulcers. Resident #119, a dependent individual, who was known to be at risk of pressure ulcer development, did not receive incontinence care in a timely manner and did not have accurate assessments of his skin condition. Resident #26, also dependent and known to be at risk of pressure ulcer development, did not receive interventions to prevent a pressure ulcer from developing on her hand. The findings for these two (2) residents led to a determination that both had experienced actual harm as a result of the facility's failure to provide needed care and services. Resident Identifiers: #119 and #26. Facility census:156. Findings included: a) Resident #119 During the Long-Term Care Survey Process screening, on 04/23/18 at 11:37 AM, Resident #119 stated he had a pressure ulcer on his buttock from sitting in urine for 30 minutes or longer. He explained he tried to use a urinal, but sometimes he did not get all the urine in the urinal. Medical record review identified he scored 15 on the Brief Interview for Mental Status, indicating he was cognitively intact. His [DIAGNOSES REDACTED]. There was no mention of current pressure ulcers found in the resident's record. Review of Skin Check Performed Sheets dated from 1/27/18 to 4/23/18 found the following documentation: - 01/27/18 - No Skin Injury/Wounds by Licensed Practical Nurse (LPN) #172 - 02/04/18 - No Skin Injury/Wounds by LPN #92 - 02/10/18 - No Skin Injury/Wounds by LPN #172 - 02/17/18 - No Skin Injury/Wounds by LPN #92 - 02/24/18 - No Skin Injury/Wounds by LPN #172 - 03/03/18 - No Skin Injury/Wounds by LPN #92 - 03/10/18 - No Skin Injury/Wounds by LPN #172 - 03/17/18 - Yes Skin Injury/Wounds identified No New Skin Injury/Wounds Type of Skin Injury/Wounds Moisture Associated Skin Damage by Registered Nurse (RN) #4 - 03/24/18 - No Skin Injury/Wounds by LPN #172 - 04/02/18 - No Skin Injury/Wounds by RN # 4 - 04/07/18 - No Skin Injury/Wounds by LPN # 33 - 04/23/18 - No Skin Injury/Wounds by LPN # 92 Review of the resident's annual minimum data set (MDS) assessment, with an assessment reference date or 03/28/18 found the resident was identified as being at risk for pressure ulcer development, that he was frequently incontinent of bowel and bladder, and required the extensive assistance of 2 or more staff for personal hygiene. The assessment had triggered for pressure ulcers and was marked to indicate it would be care planned. On 04/25/18 at 9:15 AM, Wound Care Nurse #120 agreed to do a complete skin assessment with the surveyor observing. With the resident's permission, Wound Care Nurse #120 pulled the sheets back and found a very large red excoriation on the resident's upper outer thighs. Further examination identified broken skin under his scrotum and on his coccyx. The resident's tee shirt was saturated with urine up his back and had small amount of stool on the bottom of the shirt. According to the resident, Nurse Aide (NA) #96 had changed him earlier, therefore the nurse aide left him like this. Wound Care Nurse #120 removed the tee shirt. Wound Care Nurse #120 asked Resident #119 how long had his skin been in that condition? The resident responded a year, that it had started after being on this floor for a week. During an interview on 04/25/18 at 9:35 AM, Wound Care Nurse #120 stated he was just mortified by what was just discovered, referring to the condition of Resident #119's skin. He went on to say he had no excuse and they had failed this resident. On 04/25/18 at 9:45 AM, when informed of the findings for Resident #119, the director of nursing (DoN) stated she was aware of the problem and was working on a plan of correction. The results of the complete skin audit provided by Wound Care Nurse #120 were: 1. Pressure Ulcer Stage II on Coccyx 2. Pressure Ulcer Stage II on right ear 3. Excoriated areas bilateral groin, under both breast, bilateral abdominal folds, bilateral upper outer thighs and bilateral calf's. 4. Reddened area to the right great toe, second and third toes, right heel. Resident #119's care plan, initiated on 04/03/17, identified the resident had impaired skin integrity due to his psoriasis and Moisture Associated Skin Damage (MASD). A history of pressure ulcers was noted. The interventions for this problem included: - Monitor skin for signs/symptoms of skin breakdown i.e. - Observe skin condition with ADL care daily and report abnormalities - Skin check per policy - Weekly skin assessment by license nurse - Weekly wound assessment The facility's policy, NSG236 Skin Integrity Management, Effective date 07/01/01, Revision date 11/28/16, included staff were to continually observe and monitor for skin changes and implement revisions to the plan of care. The purpose was to provide safe and effective care to prevent the occurrence of pressure ulcers and promote healing of all wounds. The failure of the facility to assess and monitor this resident who was identified as at risk of pressure ulcer development, had triggered pressure ulcers on his annual MDS, had multiple risk factors for pressure ulcer development, and failure to follow/implement its own policy, resulted in actual harm to this resident. b) Resident #26 Observation of the resident at 4:45 p.m. on 04/23/18, found both the resident's left and right hands appeared contracted. The resident had no splinting devices in use. When asked if the resident could open her hands, the resident's nurse aide (NA), NA #149, said, she could open one hand but, I would probably break her fingers if I tried to open the other hand, and I'm not going to do that. NA #149 said the resident's left hand would not open. She was not sure how long the resident had been unable to open her left hand. Review of the medical record at 11:30 a.m. on 04/25/18, found the resident had no orders for any splinting devices to either hand. The most recent minimum data set (MDS), a quarterly, with an assessment reference date (ARD) of 01/25/18, noted the resident did not have any contractures and did not have any pressure areas. Review of the current care plan found no reference to any contractures or pressure wounds. At 1:41 p.m. on 04/25/18, the occupational therapist (OT), OT #171 said the resident had received occupation therapy and was discharged from OT on 01/26/18. When we discharged her, she didn't have any hand contractures, she didn't need any interventions. Observation of the resident at 1:44 p.m. on 04/25/18, with OT #171 revealed the following: OT #171 was able to open the residents right hand with without difficulty. When opened, a sour odor, coming from the right hand was evident. OT #171 said she had sinuses and couldn't smell the odor. When OT #171 attempted to open the left hand, a strong putrid, foul smelling, sour odor, radiated from the left hand. OT #171 did acknowledge she could smell the odor coming from the left hand. OT #171 said she would get staff to clean the resident's hands. OT #171 was unable to fully extend all the fingers of the left hand. The ring finger was pressed into the palm of the resident's hand. It was evident the fingernail was cutting into the palm of the resident's hand. OT #171 said, She was never like this when we finished with therapy services in January. When OT #171, discarded her gloves in the trash can in the corner of the resident's room, the foul odor from the gloves could be smelled coming out of the trash can. Throughout the observation, the resident said, Ouch, that hurts, that hurts, when OT #171 was attempting to work with the resident's left hand. The resident also said, I need my fingernails cut, the doctor said so. The resident nails were long jagged and unclean. These observations were discussed with the director of nursing (DON) at 2:00 p.m. on 04/25/18. The DON said she would have a nurse soak the resident's hands and assess the resident to determine if the resident has a pressure ulcer to the palm of her left hand. Further review of the electronic medical record found a physician's progress note, dated 04/16/18. The physician did not note the resident's contracture of her left hand or any pressure ulcers. A skin check by facility nursing staff on 04/13/18 at 4:00 p.m. had no skin injury/wounds noted. At 2:15 p.m. on 04/25/18, Licensed Practical Nurse (LPN) #26 was observed cleaning the resident's hands and cutting her fingernails. The nurse acknowledged there was a foul odor coming from both of the resident's hands. LPN #26 said she thought she could see a, break in the skin, on the palm of the left hand. She said, I won't know for sure until I soak the hand and get it to open a little more. At 8:10 a.m. on 04/26/18, during an observation of the resident with the DON, she confirmed the resident had a Stage II pressure on her left hand, just under the ring finger on the palm of her left hand. The DON further confirmed the facility was unaware of the pressure ulcer prior to surveyor intervention. At 8:35 a.m. on 04/26/18, the DON said, I am taking care of this, calling the doctor, the residents family and will get an order for [REDACTED]., probably at least a month or longer, it would be hard to say. The DON said she was unaware of the situation and had no evidence to present to verify any interventions were implemented, such as even using a rolled washcloth in the resident's hands to prevent the fingernails from digging into the skin which lead to the development of the resident's pressure ulcer. The DON confirmed the skin check, completed by the nursing staff on 04/20/18, should have caught the problem. Review of the resident's minimum data set (MDS) assessments, found this [AGE] year-old female resident was assessed as at risk of pressure ulcer development and as requiring extensive assistance for activities of daily living since admitted on [DATE]. The resident's most recent assessment, a quarterly MDS with an assessment reference date of 01/25/18, identified she weighed 99 pounds and had functional impairment of both upper extremities. The facility failed to ensure this dependent resident, who was known to be at risk for pressure ulcers and had limitations in the use of her upper extremities, received needed care and services to prevent an avoidable Stage II pressure ulcer in her left hand. These finding led to a determination actual harm.

Based on observation, staff interview, resident interview, and record review, the facility failed to ensure four (4) of five (5) residents reviewed for positioning and mobility received appropriate treatment and services to prevent a decrease in range of motion. The facility failed to recognize Resident #26's range of motion in her hands was declining. The facility failed to provide interventions (services, care and equipment) for Resident #26 to address the decrease in range of motion. The failure to provide care lead to the development of a pressure ulcer to the palm of the Resident's left hand and pain when attempts were made to open her hand. This was determined to constitute actual harm for Resident #26. In addition, the facility failed to provide care for Resident #99 and Resident #80 who had decreases in range of motion. Resident #62 did not receive restorative nursing services as ordered by the physician. Resident identifiers: #26, #80, #99, and #62. Facility census: 156. Findings included: a) Resident #26 Observation of the resident at 4:45 p.m. on 04/23/18, found the resident's left and right hands appeared contracted. The resident had no splinting devices in use. When asked whether the resident could open her hands, the resident's nurse aide (NA), NA #149, said, I can open one hand, but I would probably break her fingers if I tried to open the other hand, and I'm not going to do that. NA #149 said the left hand would not open. She was not sure how long the resident had been unable to open that hand. Review of the medical record at 11:30 a.m. on 04/25/18, found the resident had no orders for any splinting devices for either hand. The most recent minimum data set (MDS), a quarterly assessment, with an assessment reference date (ARD) of 01/25/18, noted the resident did not have any contractures, nor did she have any pressure areas identified. Review of the resident's current care plan found no reference to any contractures. The care plan did include a focus/problem of, Resident requires assistance with ADL's (activities of daily living) due to limited mobility. The goal associated with the problem was, Residents/Patients ADL care needs will be anticipated and met throughout the next review period. Interventions included: - Monitor for decline in ADL function. Refer to rehabilitation therapy and decline in ADL's is noted. - Provide resident extensive assist for bed mobility, dressing, eating, personal hygiene, and grooming. At 1:41 p.m. on 04/25/18, the occupational therapist, OT #171, said the resident had received occupation therapy and was discharged from OT on 01/26/18. When we discharged her, she didn't have any hand contractures, she didn't need any interventions. Observation of the resident at 1:44 p.m. on 04/25/18, with OT #171 revealed OT #171 opened the resident's right hand without difficulty. When opened, a sour odor, coming from the right hand was evident. OT #171 said she had sinuses and could not smell the odor. When OT #171 attempted to open the left hand, a strong putrid, foul smelling, sour odor, emanated from the resident's left hand. OT #171 did acknowledge she could smell the odor coming from the left hand. OT #171 said she would get staff to clean the resident's hands. OT #171 was unable to fully extend all the fingers of the left hand. The ring finger was pressed into the palm of the resident's hand. It was evident the fingernail was cutting into the palm of the resident's hand. OT #171 said, She was never like this when we finished with therapy services in January. When OT #171, discarded her gloves in the trash can in the corner of the resident's room, the foul odor from the gloves could be smelled coming out of the trash can. Throughout the observation, the resident said, Ouch, that hurts, that hurts, when OT #171 was attempting to work with the resident's left hand. The resident also said, I need my fingernails cut, the doctor said so. The resident nails were long jagged and unclean. These observations were discussed with the director of nursing (DON) at 2:00 p.m. on 04/25/18. The DON said she would have a nurse soak the resident's hands and assess the resident to determine if the resident had a pressure ulcer to the palm of her left hand. Further review of the electronic medical record found a physician's progress note dated 04/16/18. The physician did not address any issues regarding the resident's hands. The physician addressed only mild contracture of the resident's legs. The physician's plan: She is at last stage of life, will consider referring to hospice if MPOA (medical power of attorney) agrees. The physician did not note any contractures of the resident's left hand or any pressure ulcers. The skin check performed by facility nursing staff on 04/13/18 at 4:00 p.m. had no skin injuries/wounds noted. Observations noted Licensed Practical Nurse (LPN) #26 cleaning the resident's hands and cutting her fingernails at 2:15 p.m. on 04/25/18. LPN #26 acknowledged there was foul smelling odor coming from both of the resident's hands. LPN #26 said she thought she could see a, break in the skin, on the palm of the left hand. She said, I won't know for sure until I soak the hand and get it to open a little more. At 3:15 p.m. on 04/25/18, Employee #170, the director of rehabilitation services, said the resident was screened for services on 04/19/18. E #170 said, When we screen a resident we can't touch them. If the patient can't tell us what is wrong or the staff don't tell us we don't know. She said the resident did not want any therapy, but did agree to a speech evaluation. E #170 said the resident had no contractures of her hands when discharged from OT services on 01/26/18. The therapy screen dated 04/19/18 noted, Resident per staff (symbol for increased) confusion/resident is not out of bed compliance due to medical decline per resident does not want any therapy. However did agree to a ST (speech therapy) evaluation or further screen. At 3:17 p.m. on 4/25/18, when these findings were discussed with the DON, she said she was unaware a therapist could not touch a resident during a screen. At 8:10 a.m. on 04/26/18, during an observation of the resident with the DON, she confirmed the resident had a Stage II pressure on the left hand, just under the ring finger on the palm of the hand. The DON further confirmed the facility was unaware of the pressure ulcer prior to surveyor intervention. At 8:35 a.m. on 004/26/18, the DON said, I am taking care of this, calling the doctor, the resident's family and will get an order for [REDACTED]. When asked how long she would estimate the resident's left hand had been contracted, she replied, I don't know, probably at least a month or longer, it would be hard to say. The DON said she was unaware of the situation and had no evidence to present to verify any interventions were implemented, such as even using a rolled washcloth in the resident's hands to prevent the fingernails from digging into the skin which lead to the development of the resident's pressure ulcer. The DON confirmed the skin check, completed by the nursing staff on 04/20/18, should have caught the problem. The DON was unable to provide any verification the facility addressed the resident's contracted left hand before surveyor intervention. The facility failed to ensure the resident received ADL care which was evidenced by the foul odor of the resident's hands. Had ADL care been provided to the resident's hands, staff would have identified the developing contracture of the resident's left hand. The failure to address the developing contracture resulted in the resident experiencing pain when care was provided after the hand contracted, and resulted in a Stage II pressure ulcer. The failure to provide needed care for this resident constituted actual harm. b) Resident #80 Observation on 04/23/18 at 3:40 p.m. found this resident lying in bed. He had contractures of both hands. There were no splints, palm guards, or any type of device in place to either hand. Observation on 04/24/18 at 10:30 a.m. found him resting in bed with his eyes closed. No splints, rolled wash cloths, or palm guards were in place. He held both hands firmly closed. At 12:15 p.m. on 04/24/18, accompanied by E#13, observations noted a white washcloth placed partially in his left hand, and a thin, smaller, yellow-colored cloth was placed partially in his right hand. When asked whether the cloths were placed in the resident's hands after 10:45 a.m., E#13 replied in the affirmative and said she had placed them. E#13 tried to move the resident's contracted fingers so the palms could be visualized. His fingers were drawn down tightly, which made visualization of the palm inadequate. E13 could move the resident's right thumb about one-quarter of an inch outward, allowing visualization of a dry, reddened area on the skin of the fourth finger of the right hand. The thumbnail of the right hand lay directly on top of, and was pressing against the reddened area of the fourth finger. The right thumbnail was smooth, but long, protruding beyond the flesh of the tip of the thumb. At 3:15 p.m. on 04/24/18, E#171 and wound nurse/registered nurse E#120 went to the resident's bed. A white wash cloth and a thinner yellow cloth lay on his chest. E#120 said they were aware of the reddened area on the resident's right fourth finger and were monitoring and treating it. He said the right thumbnail needed trimmed. Review of the medical record on 04/24/18 found a physician's order dated 11/22/17 to place a clean wash cloth in the right palm (to separate the right thumb and right fourth finger) every shift related to contracture of muscle of the right hand. Review of the resident's care plan found an intervention on page 3 to use bilateral palm guards between 10:00 a.m. and 2:00 p.m. daily, and they could be removed for hygiene. On page 32, a problem of actual skin breakdown to the right fourth finger was noted. Interventions included to observe skin condition with activities of daily living (ADL) care daily and report abnormalities, provide wound treatment as ordered, and weekly skin assessments by the licensed nurse. The (MONTH) (YEAR) treatment administration record (TAR) contained a directive to place a clean washcloth in the resident's right palm (to separate the right thumb and right fourth finger) every shift related to contracture of the muscle. It contained another directive to apply no sting skin prep to the right fourth finger twice daily and prn (as needed). Observation on 04/25/18 at 9:10 AM found no cloths, palm guards, or any devices in either hand. Observation on 04/25/18 at 2:25 p.m., accompanied by licensed nurse Employee #80 (E#80) found no cloths, palm guards or any devices in either hand. When asked why there was no padding or cloth to the right hand, E#80 threaded the yellow cloth to the resident's right hand and ensured it padded the skin between the right thumbnail and the reddened area to the fourth finger of the right hand beneath it. The thumbnail of the right hand protruded about one-quarter of an inch beyond the top of the skin on the right thumb, and gouged into the fourth finger beneath. E#80 agreed the thumbnail was too long. She obtained some clippers, and said she would trim that offending right thumbnail right then. On 04/25/18 at 6:00 p.m., the director of nurse was informed that the nurse on 04/24/18 at 3:15 p.m. stated his right thumbnail was too long, and spoke awareness that they were monitoring and treating the reddened skin area to the right fourth finger upon which the right thumb and thumbnail rested upon. She was also informed that the following day, on 04/25/18 at 2:25 p.m., the right thumbnail was still long and in need of trimming. She was informed that although the physician ordered, and the TAR directed to place a clean washcloth in the right palm to separate the right thumb and right fourth finger, a cloth was not found in place during observations on 04/23/18, 04/24/18, and 04/25/18. The DON said the care plan should have been changed to delete the palm guard, as there is no physician's order for a palm guard. She said the physician's orders and the TAR orders should have been followed for the clean wash cloth in the right palm every shift related to contracture of the muscle. These findings were shared with the administrator on 04/26/18 at approximately 9:30 a.m. No further information was provided by the facility prior to exit. c) Resident #99 Observation on 04/23/18 at 12:00 p.m. noted the resident's left wrist was contracted, and her fingers curled into the palm of her hand. She wore no splint or device of any type to the left hand. Observation on 04/24/18 at 10:45 a.m., accompanied by registered nurse Employee #13 (E#13), found the resident wore no palm guard, had no rolled washcloth or any device for her left hand. E#13 gently stretched the fingers of the resident's left hand so the palm was visible. The resident had a partial thickness skin loss in the fold between the thumb and index finger of the left hand, that the nurse said she was unaware of this skin breakdown between the thumb and index finger of the left hand prior to this observation. Upon inquiry, the resident said she used to use a palm guard to the left hand, but thought someone took it. She said she would use it if she had it. When asked whether the resident ever used a rolled washcloth, or why she was not using a palm guard, E#13 said she thought the palm guard was discontinued. She said they used to place a rolled washcloth in the resident's left hand, but thought that therapy only used a rolled washcloth for certain hours of the day now. When asked whether she had used the rolled washcloth that day or the day before, the resident replied in the negative. During an interview with occupational therapist Employee #171 on 04/24/18 at 2:30 p.m., she said the resident's non-compliance over the years contributed to the contracture of her left hand. She said the resident was not agreeable with using the palm protector. She said the resident was agreeable with the rolled washcloth daily that could be removed for hygiene. She said the resident had it available night and day to help with skin integrity and to prevent worsening of the contracture. Medical record review on 04/24/18 also found that the (MONTH) treatment administration record (TAR) contained a directive to use the hand roll to the left hand from 8:00 a.m. to 12:00 noon daily. Nursing staff initialed its use 03/01/18 daily until 03/21/18 when she was admitted to the hospital. The (MONTH) (YEAR) TAR, reviewed on 04/24/18, contained no mention of any type of treatment modality for the contracted left hand. The resident's current care plan directed the resident have a hand roll in her left hand from 8:00 a.m. to 12:00 p.m. daily, and that it could be removed for skin checks and hygiene. This plan, initially created 11/08/17 and revised 04/05/18, included a goal for the resident to have no signs of skin breakdown through the next review. Observation on 04/25/18 at 9:00 a.m. found her asleep with no hand roll in her left hand. On 04/25/18 at noon the resident was awake and said she had not had the rolled cloth in her hand that day at any time. On 04/25/18 at 6:00 p.m., these findings were shared with the director of nursing (DON). These findings were shared with the administrator on 04/26/18 at approximately 9:30 a.m. No further information was provided by the facility prior to exit. d) Resident #62 On 10/12/17, the physician wrote an order for [REDACTED]. According to the Restorative Nursing Record, -- RNP services began on Tuesday, 10/17/17. Resident #62 received three (3) days of RNP services that week. -- During the week of 10/22/17-10/28/17, Resident #62 received three (3) days of RNP services. -- During the week of 10/29/17-11/04/17, Resident #62 received three (3) days of RNP services. -- During the week of 11/05/17-11/11/17, Resident #62 received five (5) days of RNP services. -- During the week of 11/12/17-11/18/17, Resident #62 received five (5) days of RNP services. -- During the week of 11/19/17-11/25/17, Resident #62 received six (6) days of RNP services. -- Resident #62 received RNP services on 11/27/17, 11/28/17, and 11/29/17. -- RNP services ended on 11/29/17. During an interview on 04/25/18 at 3:47 PM, the Center Nurse Executive (CNE) agreed Resident #62 did not receive RNP services six (6) times a week as ordered during the following weeks: 10/22/17-10/28/17 10/29/17-11/04/17 11/05/17-11/11/17 11/12/17-11/18/17 The CNE stated Resident #62 received RNP services through 01/03/18 as ordered by the physician. However, she stated she could not locate Restorative Nursing Records for (MONTH) (YEAR) or (MONTH) (YEAR). The CNE stated she could not explain why the Restorative Nursing Records for (MONTH) (YEAR) stated RNP services ended on 11/29/17.

Based on record review, staff interview, resident interview, and observations, the facility failed to provide the necessary care and services to maintain and/or attain the highest practicable physical mental and psychosocial well-being for three (3) of eight (8) sampled residents. Resident #107 made repeated complaints of pain during occupational and physical therapy, and also voiced these complaints to the nurse aide who took care of her on a regular basis. Her pain interfered with her ability to participate in therapy and hindered her ability to receive showers, which she identified as her preferred method of bathing. The facility failed to assess and/or treat the resident's pain, and failed to provide her with an effective pain management regimen. This constituted actual harm for Resident #107. Resident #157 did not receive sliding scale insulin as ordered by the physician. The facility also failed to provide him with a [MEDICAL CONDITION] (bilevel positive airway pressure) machine, which he utilized in the hospital prior to admission. Additionally, the facility failed to arrange for the resident to have an outpatient sleep study upon discharge from the facility as ordered by the attending physician. Resident #79 was provided oxygen upon her readmission to the facility without a physician's orders [REDACTED]. Resident Identifiers: #107, #157, and #79. Facility Census: 156. Findings Include: a) Resident #107 A review of Resident #107's medical record, at 4:44 p.m. on 03/23/15, revealed Resident #107, a [AGE] year-old female, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. 1. Review of Resident #107's care plan revealed it was her preference to receive a shower instead of a bed bath. Resident #107's activities of daily living flow sheet and the facility shower records indicated Resident #107 received only one (1) of fifteen (15) scheduled showers from 02/12/15 through 03/23/15. For the other fourteen (14) opportunities for showers, Resident #107 received a bed bath instead of a shower. During an interview with Registered Nurse (RN) #11, at 3:56 p.m. on 03/25/15, the nurse said Resident #107 was scared to take a shower. When asked how she came to this conclusion, RN #11 stated, (Name of Nurse Aide (NA) #116) took her to the shower when she was first admitted and it "petrified" the resident. She indicated they decided to just give the resident bed baths from then on because she was scared of the shower. RN #11 stated she forgot to write a note about this and she forgot to update Resident #107's care plan to reflect her fear of the shower. She indicated NA #116 would be working the following day if he needed to be interviewed. An interview with Resident #107, at 10:00 a.m. on 03/26/15, revealed she received a shower earlier that morning. The resident indicated they had washed her hair and she liked it. When asked if she was afraid to take a shower, she stated, "No. " She further indicated she had never been afraid to take a shower, she just could not sit up. When asked if she had received the number of showers she wanted while at the facility, the resident shook her head to indicate she had not. An interview with NA #116, at 10:44 a.m. on 03/26/15, confirmed Resident #107 had never been fearful to take a shower. When asked why she received bed baths instead of showers he stated, "Because she cannot sit in the shower chair for too long without crying in pain." He further stated, "Every time she sits up she cries in pain and tells us her bottom and back hurt and she will ask to lie back down in the bed." He stated, "It has never been because she is afraid. It is all about her bottom and her back hurting when in the shower chair." He also stated, "She will not use the shower bed because of her [MEDICAL CONDITION]." The NA stated the resident would only go in the shower chair, and he could usually only get her hair washed before she started crying in pain. When asked if she only complained of pain while in the shower chair, he responded, "No she cries with pain when she is in the wheelchair or geri-chair." He indicated anytime she was sitting up she would complain of pain to her bottom and her back. He further stated, " Therapy knows about her pain because she will cry and complain of pain while in therapy too." A review of Resident #107's therapy treatment encounter notes, at 1:30 p.m. on 03/26/15, revealed Resident #107 was evaluated for Physical Therapy (PT) and Occupational Therapy (OT) on 02/13/15. She began therapy sessions on 02/16/15. Review of the therapy treatment encounter notes for both PT and OT found the resident made the following complaints of pain: -- 02/23/15 Certified Occupational Therapy Assistant (COTA) #144 documented the resident complained of bottom hurting when up in geri chair. -- 02/24/15 COTA #144 documented the resident mouthed, "My bottom is hurting." COTA #144 also documented the resident complained of her bottom hurting after sitting upright in the Geri Chair. -- 02/24/15: Physical Therapy Assistant (PTA) #142 documented the resident had pain toward the end of the treatment in her coccyx area and was repositioned. -- 02/26/15: COTA #144 documented the resident became tearful toward the end of the treatment session with complaints of back pain. -- 02/26/15: PTA #142 documented resident mouthed, "My back and stomach hurt." She further documented Resident #107 was sitting in a geri-chair initially and was then placed back in bed secondary to complaints of pain to her back and stomach. She further documented Resident #107 tolerated the treatment poorly, but when she was seen in bed she did well. -- 03/02/15: COTA #144 documented the resident was always complaining of her bottom hurting. -- 03/02/15: PTA #142 documented the resident's complaints of pain continued throughout treatment. She noted Resident #107 frequently required assistance with repositioning while up in chair due to complaints of pain and pressure relief. -- 03/03/15: COTA #144 documented the resident was crying during the therapy session with complaints of her back and bottom hurting. She further noted the resident was crying due to her back hurting when the geri-chair broke and would not raise up to a sitting position. The resident had decreased complaints of back pain when transferred to a wheelchair. The resident wanted to return to bed after being up for a half hour in wheelchair. -- 03/03/15: PTA #142 noted the resident was in geri-chair and that upon attempting to sit her up, the geri-chair would not release from feet and head reclined. They transferred the resident into a wheelchair for trial in tolerating and positioning. The wheelchair had elevated bilateral footrests, a Roho cushion (a seat cushion designed to provide pressure relief) and a pillow was positioned under the resident's right arm. PTA #142 noted she asked the resident if her bottom was hurting and Resident #107 mouthed, "No, and stated she liked the wheelchair." PTA #142 documented she completed the treatment and took Resident #107 to her room at which time the resident asked to be laid down on the bed. The PTA documented she turned on the call light and handed it to the resident. She noted she went out and spoke with Resident #107's nurse and told LPN #87 the resident wanted to go to bed. LPN #87, who was getting pills out of the medication cart stated, "Too bad she would have to wait because she was busy with other things and it was almost lunch time and she did not know where the aides were so she would just have to wait, " The PTA noted the LPN then walked down the hall. -- 03/04/15: COTA #144 noted the resident was crying during a treatment session while sitting on the edge of bed stating her butt hurt. -- 03/05/15: COTA #144 noted resident continued to complain of her bottom hurting due to open areas. -- 03/06/15: COTA #144 noted the resident had open wounds on her buttocks causing her not to tolerate sitting up. She further noted the resident had had diarrhea the past two (2) treatment sessions and treatment had been performed in the resident's room. She noted at the start of treatment on that day, the resident was in bed on her back and was agreeable to participate -- 03/09/15: COTA #144 documented the Resident reported her bottom was "really hurting." -- 03/10/15: COTA #144 documented the resident reported her butt was hurting. She further noted Resident #107 "Was crying stating, 'my butt hurts' also complains of her butt hurting while laying in bed. As soon as patient was laid back in bed tears stopped instantly." -- 03/10/15: PTA #142 noted the resident was mouthing she wanted to lay down because her bottom was hurting. -- 03/17/15: PTA #142 documented the resident reported her back was hurting when sitting up. -- 03/18/15: COTA #144 noted the resident complained of back pain when sitting unsupported. -- 03/18/15: PTA #142 noted the resident was crying off and on during therapy sessions with complaints of back pain. -- 03/19/15: COTA #144 noted the resident was crying during therapy session stating her back and/or bottom were hurting. She noted the resident was trying to get out of the therapy session and when she returned to her room, the crying stopped. -- 03/20/15: COTA #144 noted the resident stated, "I can't my butt hurts." She also noted the resident always cried during therapy sessions and could stop instantly if she wanted to. -- 03/20/15 PTA #142 noted the resident complained of her leg and back hurting and was crying off and on during the therapy session. An interview with PTA #142, at 3:35 p.m. on 03/26/15, confirmed Resident #107 had frequent complaints of pain when in therapy. She reported they were almost daily. PTA #142 stated when she was able to see Resident #107 in her room, she did better because she was in bed. When asked if she felt Resident #107 had pain, she indicated she thought she had some pain, but that she may complain a little more than necessary. Further review of Resident #107's medical record found a physician's orders [REDACTED]. Review of Resident #107's narcotic sheets for this medication found she received the medication two (2) to three (3) times daily from 02/17/15 to 02/26/15. When the narcotic sheet was compared to the Medication Administration Record [REDACTED]. The following doses were administered, but did not indicate why the PRN pain medication was given, or if it was effective in relieving her pain: -- 02/17/15 at 11:00 a.m. -- 02/18/15 at 9:00 a.m., 2:00 p.m., and 9:00 p.m. -- 02/19/15 at 9:00 a.m., and 6:00 p.m. -- 02/20/15 at 1:00 a.m. -- 02/23/15 at 12:00 p.m. and 11:00 p.m. -- 02/24/15 at 2:00 p.m. and 11:00 p.m. -- On 02/26/15 a physician's orders [REDACTED]. -- On 03/15/15, a readmission order for [MEDICATION NAME] 5/325 milligrams via feeding tube four (4) times a day as needed for pain was entered into the medical record. -- The following day, on 03/16/15, a physician's orders [REDACTED]. (This was the previous order prior to the resident's discharge to the hospital on [DATE].) -- On 03/25/15, on readmission, the physician ordered [MEDICATION NAME] 5/325 milligrams via feeding tube every eight (8) hours at 6:00 a.m., 2:00 p.m., and 10:00 p.m. for pain. (Resident #107 was taking this dosage of medication at this frequency prior to her discharge to the hospital on [DATE].) Additional review of the medical record found no evidence therapy ever communicated to nursing Resident #107's complaints of pain. The nursing progress notes were reviewed and found the following instances when Resident #107's pain was mentioned. -- On 02/16/15 nursing notified the physician that Resident #107 was crying at times and the attending physician gave orders for [MEDICATION NAME] 5/325 milligrams via feeding every four (4) hours for complaints of pain as needed. -- On 02/26/15, LPN #87 noted she spoke with the attending physician about the resident's pain and got a new order of [MEDICATION NAME] 5/325 three (3) times a day at 6:00 a.m., 2:00 p.m. and 10:00 p.m. There was no indication as to what pain this nurse addressed with the attending physician. -- Since 02/26/15, there was no other mention of Resident #107's pain in the nursing progress notes despite her complaints of pain on 02/23/15 and 02/24/15 in therapy. On 03/02/15, LPN #87 completed a pain evaluation which indicated Resident #107 had general pain. The onset of the pain was marked as "unable to determine," the pain description was marked as "unable to obtain," the question as to what makes the pain worse was marked "unable to obtain," and the question as to what makes the pain better was marked "unable to obtain." The assessment indicated the resident's acceptable level of pain was "no pain." The question as to whether the resident was satisfied with her level of pain was marked as "unable to determine/nonverbal." Under the section titled comments, the nurse documented the resident was on scheduled pain medications. This assessment was ineffective in determining whether Resident #107's current pain medication regimen was effective in alleviating her pain. The nurse failed to establish communication with Resident #107 to determine if the resident was satisfied with her level of pain. Therapy had been documenting the resident's communication of pain consistently since 02/23/15. On 03/04/15, RN #45 noted Resident #107 was having chest pains. The resident was able to rate her pain as 10 out of 10. The nurse practitioner saw the resident and treated her with [MEDICATION NAME]. The resident's chest pains subsided and the resident was able to communicate her pain was down to a zero (0), indicating no pain. On 03/04/15, RN #46 completed another pain evaluation. This was the only time Resident #107's pain to her back and buttocks was addressed by nursing, despite the fact she complained of this pain on 02/23/15, 02/24/15, 02/26/15, 03/02/15, and 03/03/15. The pain evaluation indicated Resident #107 had chronic pain to her back and buttocks. The assessment determined the pain was sharp and soreness was noted. RN #46 indicated activity and position made the pain worse. The assessment indicated position and medication would make the pain better. The question as to whether the resident was satisfied with her current level of pain management was marked as "unable to determine/non- verbal." There were no comments on this assessment. RN #46 failed to communicate with the resident to determine if her current level of pain management was satisfactory. The RN noted the resident was non-verbal, so her satisfaction was unable to be determined, even though the same day, nursing staff documented the resident was able to rate the severity of her chest pains and was able to communicate when they subsided. Additionally, Resident #107 expressed consistent complaints of pain in therapy since 02/23/15. In another interview at 2:45 p.m. on 03/26/15, when asked why she could not sit up, Resident #107 stated, "Because my back and bottom hurt." When asked if the pain in her back and bottom were the reason she did not want to get a shower and the reason why she did not always want to go to therapy, she shook her head to indicate her pain was the reason she refused showers and why she did not always want to go to therapy. When asked what staff did to help alleviate her pain, she stated, "They just hurry up and get it over with." When asked if staff provided her with pain medication or other things to help with her pain when she complained of pain, the resident shook her head to indicate they did not. During this interview, Resident #107 was lying on her back on her bed. When asked if she was having pain, she stated she was. Resident #107 was then asked to rate her pain on a scale of zero (0) to ten (10) with zero (0) being no pain and ten (10) being the worst possible pain. The resident indicated her pain was a five (5). When asked to use the same scale to determine what her acceptable level of pain would be, she stated her acceptable level of pain would be a one (1). At 2:50 p.m. on 03/26/15, LPN #87 was notified of Resident #107's complaints of pain. She was notified she rated her pain at a five (5). LPN #87 stated the resident had a pain pill due at two o'clock. She stated, "I was just going to give her pain medication." LPN #87 was observed administering the 2:00 p.m. dose of pain medication to Resident #107 at 3:08 p.m. on 03/26/15. When asked if Resident #107 ever had complaints of pain, LPN #87 said Resident #107 had not been able to communicate well because of her [MEDICAL CONDITION]. She stated, "She just now started to talk." When asked how she would evaluate her pain, she said, "Well we would ask her now, but before we could not do that." LPN #87 was then asked if Resident #107 received her 6:00 a.m. dose of pain medication. She pulled the narcotic card from the medication cart, and stated, "I just got these from the pharmacy at 10:30 a.m." When asked if the resident had a previous supply from before she went to the hospital, the LPN stated she did. The LPN checked the narcotic card (which was still available in the medication cart) and indicated the resident did not receive a pill from that card either. At 3:15 p.m. on 03/26/15, RN #11 was asked if [MEDICATION NAME] 5-325 was available for administration. She stated it was. She was then asked to see if Resident #107 was administered her 6:00 a.m. dose of this medication from the Omnicell. She confirmed the nurse had not gotten the medication from the Omnicell and had not administered the medication to Resident #107 at 6:00 a.m. on 03/26/15, even though it was available for administration. On 02/26/15, Resident #107's pain medication was changed to [MEDICATION NAME] 5/325 milligrams every eight (8) hours at 6:00 a.m., 2:00 p.m., and 10:00 p.m. Resident #107 had received this dosage of [MEDICATION NAME] at this frequency since 02/26/15, with the exception of 03/15/15 when she was readmitted from the hospital with an as needed order for [MEDICATION NAME] 5/325 four (4) times a day as needed. The following day, on 03/16/15, the attending physician changed the order back to every eight (8) hours at 6:00 a.m., 2:00 p.m., and 10:00 p.m. Resident #107 continued on this same dosage of [MEDICATION NAME] despite her complaints of pain to therapy staff on 03/02/15 through 03/06/15, 03/09/15, 03/10/15, and 03/17/15 through 03/20/15. There was no evidence the facility effectively assessed Resident #107's pain to provide optimal pain management. This interfered with the resident's ability to participate with therapy and to receive showers, which she indicated she would enjoy, resulting in actual harm for Resident #107. In an interview, at 10:38 a.m. on 03/27/15, with the Nursing Home Administrator and the Clinical Service Manager RN #140, these findings were discussed. They were unable to provide evidence the facility worked with Resident #107 to ensure the provision of optimal pain management. They agreed there was a communication failure between therapy and nursing, and perhaps that had led to some of the problems. They stated Resident #107 was a complex case, and they believed they had done their best with her. . . b) Resident #157 1. On 03/24/15, review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED] -- 12/21/14 at 6:00 a.m. finger stick value of 160 - documented 2 units of insulin refused by resident. -- 12/23/14 at 11:00 a.m. singlestick value of 165 - documented 2 units of insulin given -- 12/20/14 at 9:00 p.m. singlestick value of 159 - documented 2 units of insulin given -- 12/20/14 at 9:00 p.m. singlestick value of 157 - documented 2 units of insulin given At 4:00 p.m. on 12/24/15, the assistant director of nursing (ADON) verified, according to the MAR indicated [REDACTED]. She agreed, that according to the MAR, the resident received 2 units of insulin for the elevated blood sugars instead of the 1 unit as ordered by the physician for blood sugars between 150 and 200. According to the ADON, the MAR indicated [REDACTED]. 2. Review of Resident #157's medical record found three (3) forms, related to the use of a Bi-level positive airway Pressure ([MEDICAL CONDITION]) machine accompanied the resident on admission to the facility on 12/18/14. -- "Pre-Admission Review (PAR) dated and signed on 12/17/15 by registered nurse, external care coordinator (RN, ECC). The nurse documented, "...Bi-level positive airway Pressure ([MEDICAL CONDITION]) which is new for this patient ... ([MEDICAL CONDITION] is used in the treatment of [REDACTED]. -- An acute care physician's assessment note dated and signed, 12/18/14 at 8:57 a.m., revealed "... Sleep apnea, twenty (20) second period of apnea noted...." (This information was sent to the nursing home when the resident was admitted .) -- A "Transfer Form" which revealed, "... other equipment: [MEDICAL CONDITION]. " Further medical record review, on 03/24/15, revealed an initial nursing assessment dated and signed, 12/18/14 at 11:30 p.m. This assessment, under section 3, indicated: "Respiratory Care Needs: [MEDICAL CONDITION]/[MEDICAL CONDITION] and oxygen at 2 liters/minute." The Admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/25/14, under Section O, respiratory treatments while not a resident was checked oxygen therapy and [MEDICAL CONDITION]/[MEDICAL CONDITION]. Under the part for while a resident, the assessor only checked oxygen therapy. Review of nurses' progress notes, on 03/24/15 at 11:00 a.m., found on 01/25/15 at 11:30 p.m., Registered Nurse (RN) #7, wrote, "... respirations even and non-labored with the exception of nighttime where the resident exhibits periods of breathing/gasping for air. Patient on the list to see (Name of the Physician) in am...." A physician progress notes [REDACTED]. Arrange for an outpatient (OP) sleep study...." A physician's orders [REDACTED]. On 03/24/15, record review found no evidence the facility scheduled the outpatient sleep study for Resident #157 before he was discharged to home on 02/28/15. Interview on 03/24/15 at 1:00 p.m. with the ADON, confirmed the facility failed to schedule the sleep study and the "Discharge Transition Plan" had no information concerning the need to schedule a sleep study. On 03/24/15 at 2:07 p.m., Licensed Practical Nurse (LPN) #127 wrote, "... outpatient sleep study scheduled for 04/01/15 .... " This was after the issue was brought to the ADON's attention on 03/24/15, and after the resident was transferred home on 02/28/15. c) Resident #79 On 03/23/15 at 11:30 a.m.,observation revealed the resident was receiving oxygen per a nasal cannula at 2 liters per minute. Medical record review revealed a physician's orders [REDACTED]. An additional review of the medical record, on 03/27/15 at 9:30 a.m., found a readmission nursing assessment completed by RN #136, for the readmission on 03/02/15. The assessment, under Section 3 labeled "Respiratory Care Needs" indicated oxygen was used. The liter flow was 2 liters per minute (2 l/m). An interview with the ADON, at 2:43 p.m. on 03/25/15, verified Resident #79 was admitted with, and had been receiving oxygen since readmission on 03/02/15. She confirmed the order for the resident to receive oxygen was not written until 03/25/15. .

Based on record review, staff interview, resident observation and policy review, the facility failed to provide the necessary care and services, in accordance with the comprehensive assessment, to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (one) of 3 (three) residents reviewed for the care area of death during Stage 2 of the Quality Indicator Survey (QIS), and for 2 (two) residents identified during random opportunities for discovery. Resident #222 was admitted to the facility on [DATE] and was unresponsive with no pulse or respirations at the facility on 11/17/14. During this thirteen (13) day stay, the facility failed to administer Resident #222's [MEDICATION NAME] in dosage prescribed by the physician, failed to hold his [MEDICATION NAME] when Resident #222's pulse fell outside the physician established parameters, and the attending physician failed to accurately assess the resident's medication regimen prior to making medication changes (regarding [MEDICATION NAME]) on 11/10/14. The facility also failed to notify Resident #222's attending physician/nurse practitioner when the resident was suffering from [MEDICAL CONDITION] (very slow heart beat) with pulses of 56, 42, and 43 over a two (2) day period. It was determined these issues resulted in actual harm to this resident. Resident #1's enteral feedings and dressing changes to his percutaneous endoscopic gastronomy (PEG) tube site were not provided as ordered by the physician. Additionally, the facility failed to provide Resident #131's pain medication as ordered by the physician. Resident Identifiers: #222, #1, and #131. Facility Census: 154. Findings Include: a) Resident #222 1. A review of Resident #222's medical record, completed at 12:56 p.m. on 12/04/14, revealed Resident #222 was a patient at a local hospital from 11/01/14 until 11/04/14, at which time he was transferred to this facility. The local hospital's referral for Resident #222, first submitted to the facility on [DATE] at 11:44 a.m., revealed the following Nurse Progress Notes written by the local hospital nursing staff (typed as written): -- "11/03/14 10:40 a.m. Patient heart rate monitored from 5 north is sinus Brady ([MEDICAL CONDITION]) 45 reported by (name of local hospital staff) Charge Nurse informed. Patient sleeping at present time. Will continue to monitor patient." -- "11/03/14 10:52 a.m. notified (name of local hospital physician) with cardiology that patient's heart rate and been running in the 30's and 40's overnight, this AM his heart rate was 45. Ordered 12 lead EKG, cardiology informed staff that patient would be seen after 5 pm today by them." Further review of the medical records from the hospital indicated the resident was seen by the cardiologist on 11/02/14 and 11/03/14. An 11/03/14 note indicated, "May consider echo (echocardiogram) to assess for WMA (wall motion abnormality), otherwise no other cardiac w/u (work up) warranted as previously discussed." Review of the history and physical from the local hospital, dated 11/02/14, contained the following in regards to Resident #222, "...heart- rate controlled irregularly...". The discharge summary from the local hospital indicated the resident was to be discharged to the nursing facility on the following medications: [REDACTED]." 2. Review of Resident #222's nursing facility medical record revealed he was admitted to the facility on [DATE] with the following physician's orders [REDACTED]. mg po twice a day for constipation." The medical record indicated Resident #222 was seen by his attending physician on 11/10/14. The physician progress notes [REDACTED]." Under the heading symptoms the following was noted (typed as written), "Pt (patient) states his bp gets this way all his life. Never had dizziness or chest pains. 88/41 on [MEDICATION NAME], HCTZ ([MEDICATION NAME]), [MEDICATION NAME]. BS (blood sugar) all good." The pulse documented on the progress note was 46 beats per minute and the blood pressure documented was 108/63. Under the section titled assessment/plan the following was documented by the physician (typed as written), "[MEDICAL CONDITION]- decrease (noted by a downward pointed arrow) [MEDICATION NAME]. D/C (discontinue) HCTZ..." Although the physician's 11/10/14 progress note indicated the resident was receiving [MEDICATION NAME], review of resident's physician orders, since the time of admission, and review of the medication administration record (MAR), since the time of admission, revealed the resident was not ordered or receiving [MEDICATION NAME] for hypertension. On 11/10/14, a hand written physician's orders [REDACTED]." These orders were transcribed to the MAR and Resident #222 began receiving [MEDICATION NAME] (a beta-blocker used to treat hypertension) 50 mg daily for hypertension on 11/11/14 at 9:00 a.m. He received this medication in addition to his previously ordered hypertension medications of [MEDICATION NAME] (a beta blocker used to treat Hypertension in the same class a [MEDICATION NAME]) 100 mg po daily and [MEDICATION NAME] (an ace inhibitor used to treat hypertension and [MEDICAL CONDITION]) 10 mg po daily. 3. An interview with the Director of Nursing (DON) at 8:25 a.m. on 12/08/14, revealed the nurse who noted the order for the [MEDICATION NAME] and added it to the MAR should have looked for the previous order of [MEDICATION NAME] to discontinue it. She stated this was a necessary step since the physician wrote to decrease the medication. She indicated when the nursing staff found there was no [MEDICATION NAME] ordered they should have called the physician and clarified the order. At 8:57 a.m. on 12/08/14, Resident #222's attending physician was interviewed. She confirmed she saw Resident #222 on 11/10/14 for [MEDICAL CONDITION] (low blood pressure blood pressure reading of 90 millimeters of mercury (mm Hg) or less systolic blood pressure (the top number in a blood pressure reading) or 60 mm Hg or less diastolic blood pressure (the bottom number) is generally considered low blood pressure). She stated she must have misread the medications and confused the [MEDICATION NAME] with [MEDICATION NAME]. She stated she did not mean to start him on another medication to treat hypertension when he was being seen for [MEDICAL CONDITION]. She stated she meant to decrease the [MEDICATION NAME] on that date but confused it with [MEDICATION NAME]. She confirmed it was a mistake and the resident should not have been started on the [MEDICATION NAME] on 11/10/14. 4. Review of the medical record revealed no evidence the physician or nurse practitioner was notified of Resident #222's [MEDICAL CONDITION] (a resting heart rate under 60 beats per minute). According to the MAR it was 56 beats per minute (bpm) at 9:00 a.m. on 11/11/14. The electronic medical record (EMR) contained documentation of a pulse of 56 bpm at 12:37 p.m. on 11/11/14 and 42 bpm at 6:00 p.m. In addition, the EMR indicated the resident's pulse was 43 bpm on 11/12/14 at 1:20 a.m. There was no evidence the physician or nurse practitioner was notified the resident was experiencing [MEDICAL CONDITION] until 11/13/14, when the resident's pulse was 48 bpm at 9:50 a.m. On 11/13/14 new orders were received from the nurse practitioner to (typed as written), "D/C [MEDICATION NAME], (due to) decrease (indicated by a downward pointing arrow) HR (heart rate) and BP (blood pressure). Decrease (indicated by a downward pointing arrow) [MEDICATION NAME] to 50 mg po daily hold SBP (systolic blood pressure) < (less than) 100 or HR < (less than) 60." Interview with DON at 8:25 a.m. on 12/08/14 confirmed the physician/nurse practitioner was not notified of the Resident #222's [MEDICAL CONDITION] until 11/13/14 when new orders were given by the nurse practitioner. 5. The medical record also contained a physician order [REDACTED]. The heart rhythm is fast and irregular in this condition)..." Review of the MAR for 11/10/14 and 11/11/14 revealed Resident #222's previous dose of [MEDICATION NAME] 2 mg was not removed from the MAR until after he received that dose on 11/11/14. The new dosage of 2.5 mg was added to the MAR on 11/10/14. The resident received both doses for a total of 4.5 mg of [MEDICATION NAME] on 11/10/14 and 11/11/14. An interview with the Director of Nursing (DON) at 2:00 p.m. on 12/04/14, confirmed the facility administered the wrong dose of [MEDICATION NAME] on 11/10/14 and 11/11/14. 6. Review of Resident #222's MAR for 11/14/14 through 11/16/14 revealed the following medication, "[MEDICATION NAME] 50 mg po qd (one time a day) dx (diagnosis)[MEDICAL CONDITION](hypertension) hold SBP <100 or HR < 6 (This was a transcription error and should have been 60). Further review of the MAR revealed on 11/14/14, the resident's pulse was 53 bpm, on 11/15/14 the resident's pulse was 51 bpm, and on 11/16/14 the resident's pulse was 53 bpm. On all three (3) occasions the resident's [MEDICATION NAME] was administered despite his pulse being below the physician established parameter of 60 bpm. The DON, at 2:00 p.m. on 12/04/14, confirmed facility staff administered the [MEDICATION NAME] 50 mg on 11/14/14, 11/15/14 and 11/16/14, when the resident's pulse was below 60 bpm. She stated the medication should not have been administered. 7. During the resident's thirteen (13) day stay, the facility failed to administer the resident's dose of [MEDICATION NAME] as prescribed by the physician, failed to hold his [MEDICATION NAME] when his pulse fell outside the physician ordered parameters, and failed to consult the attending when the physician ordered a decreased dose for a medication ([MEDICATION NAME]) the resident had not been receiving. prior to making medication changes (regarding [MEDICATION NAME]) on 11/10/14. The facility also failed to notify Resident #222's attending physician/nurse practitioner when the resident experienced [MEDICAL CONDITION] with pulses of 56, 42, and 43 over a two (2) day period. On 11/17/14, the resident was found to be unreponsive with no pulse or respirations. The facility failed to ensure the resident received appropriate care and treatment resulting in actual harm to the resident. . . b) Resident #1 1. Observation of the resident, at 11:28 a.m. on 12/08/14, with licensed practical nurse (LPN), Employee #13 found a bag of [MEDICATION NAME] 1.5 infusing. The [MEDICATION NAME] 1.5 was dated 12/08/14 at 8:00 p.m. It contained approximately 1300 milliliters (ml) of the tube feeding formula. Upon inquiry, Employee #13 stated the date on the feeding must be incorrect. 2. Review of the physician's orders [REDACTED]. The total nutrient was 1170 ml every 24 hours. Each ready to hang bag of [MEDICATION NAME] 1.5 contained 1500 ml. During the review of the physician's orders [REDACTED]. Employee #13 said, some use the pump and some don't to ensure the resident receives the tube feeding. She further confirmed she turns the feeding pump off at 2:00 p.m. as directed by the medication administration record. 3. Observation on 12/08/14 at 11:40 a.m., with registered nurse (RN), Employee #79. Upon inquiry, Employee #79 stated the date was incorrect on the bottle of [MEDICATION NAME]. She then checked the pump used to infuse the tube feeding. The pump showed the resident had received 192 ml of [MEDICATION NAME]. She further confirmed the facility had not kept an accurate record of the amount of [MEDICATION NAME] the resident received. 4. During an interview with the director of nursing (DON), at 4:00 p.m. on 12/08/14, she stated, "We should be using the feeding pump to ensure the resident receives the ordered tube feedings." The facility failed to maintain and evaluate the feedings to ensure the resident received the needed nutritional feedings. 5. Observation of the resident, at 11:28 a.m. on 12/08/14, with licensed practical nurse (LPN), Employee #13 found a dressing around the site of the feeding tube with a moderate amount of dark brown/black crusty drainage around the site as well as on the dressing. No date on the dressing to indicate when the dressing had been applied. Upon inquiry, Employee #13 confirmed the dressing did not have a date. 6. During the review of the physician's orders [REDACTED]. 7. During an interview with the director of nursing (DON), at 4:00 p.m. on 12/08/14, she stated, "The dressings are to be changed daily on the night shift and it is the facility's policy to date dressings when changed." c) Resident #131 1. Observation of the medication pass, at 9:05 a.m. on 12/08/14, with licensed practical nurse, Employee #43. Resident #131 approached the medication cart and informed Employee #43, "I have not received my pain pill since yesterday and I really need it. Upon inquiry, Employee #43 stated the pain medication is scheduled routinely. 2. During review of the physician's orders [REDACTED]." 3. The medication administration record was reviewed and was found Employee #11 licensed practical nurse had initialed the medication at 3 a.m. on 12/08/14. Review of the controlled medication record found the medication had not been given. 4. During an interview with the director of nursing (DON), at 4:00 p.m. on 12/08/14, confirmed Resident # 131 did not receive her prescribed pain medication on 12/08/14 at 3:00 a.m. .

Based on medical record review and staff interview, the facility failed to provide an environment that was free from accident hazards, over which the facility had control, for one (1) of four (4) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). The resident had a history of [REDACTED]. Resident #25 had experienced an injury on 03/31/14. The facility had not ensured interventions were implemented to prevent additional falls from occurring. The facility also failed to lock a storage cabinet in the Unit 1 shower room. The cabinet contained items that were potentially hazardous when inhaled, ingested or came into contact with skin or eyes. This had the potential to affect more than a limited number of residents on Unit 1. Resident identifier: #25. Facility census: 154. Findings include: a) Resident #25 Review of the medical record, on 12/10/14 at 10:00 a.m., revealed the resident had an order, dated 10/20/14, to "Transfer to hospital for evaluation and treatment related to fall." An "incident detail," dated 12/20/14 at 2:00 p.m., was reviewed on 12/10/14. It noted the resident was in her geri- chair outside of her room and the resident was leaning over ar of chair reaching for the hand rail on the wall and she fell out of the chair and hit her head on the floor. The report also indicated staff observed a laceration "above the right eye with bruising." The MDS with an assessment reference date (ARD) of 10/01/14, was reviewed on 12/10/14 at 11:00 a.m. The MDS revealed a brief interview for mental status (BIMS) score of 00, which indicated "severe impairment." Section (G) noted transfers required extensive assist (non-weight bearing) of two (2). The MDS also noted the resident's balance was unsteady. Review of comprehensive care plan with a completed review date of 10/17/14, revealed the following : Focus, "Resident is at risk for falls: impaired mobility, impaired cognition and incontinence and resident will continue to be able to use her wheelchair independently or with limited assist on the unit over the next 90 days." Goals, "Resident will have no falls with injury for ninety (90) days and the resident will continue to be able to use her w/c independently or with limited assist on the unit over the next 90 days." Interventions, "Dycem to wheelchair, low bed with landing strips, resident has a self release seatbelt for safety and is able to demonstrate on command removal of the seatbelt. Her daughter has requested this seatbelt. Staff to ensure the resident has this on while up and monitor for pressure."Review of the occupational therapy evaluation and progress notes, revealed Resident #25, received occupational therapy from 07/08/14 through 08/06/14 for a reported "right lateral lean." No referral had been received for Resident #25 prior to her fall on 10/20/14. On discharge from therapy the recommendations were for the resident to be seated in a wheelchair with bilateral bolsters on arm rests and a knee separator. The resident was tolerating up to four (4) hours in with the positioning devices. During an interview with the director of nursing (DON) on 12/10/14 at 4:00 p.m.,confirmed the facility had not implemented the interventions to further reduce the risk for injury. b) Resident shower room on Unit 1 Observation of Unit 1's shower room with Registered Nurse (RN) #165 on 12/01/14 at 12:45 p.m., revealed an unlocked door into the shower room. Inside the shower room was a light tan in color plastic cabinet with an unlocked lock on the cabinet. Inside the cabinet were twenty- five (25) disposable razors, seven (7) bottles of shampoo and body wash, and three (3) cans of shaving cream. The RN agreed the items should have been locked up. She stated she would make sure the cabinet was locked. Review of the facility's material safety data sheets on 12/04/14 at 1:00 p.m., revealed they included hazard identification for shaving cream "If any eye contact, flush with water, inhalation (prolonged) requires a person to be remove to fresh air, and ingestion is to induce vomiting. If the body wash can cause temporary moderate eye irritation. Ingestion may result in gastric disturbance." Review of the facility's policy on 12/04/14 at 1:05 p.m., revealed storage areas were to be locked when not in operation to prevent unauthorized access. .

Based on medical record review and staff interview, the facility failed to assess and monitor a resident with a history of [MEDICAL CONDITION] and an indwelling Foley urinary catheter, to prevent complications associated with this invasive intervention. Resident #157 had an indwelling urinary catheter inserted on 07/18/11 to treat [MEDICAL CONDITION]. Fluid output records completed by the nursing assistants noted there had been only 50 cc of urinary output from this indwelling catheter during the three-day period prior to her acute hospitalization on [DATE], with 0 cc recorded on 08/17/11 and 08/18/11, and only 50 cc recorded on 08/19/11. The fluid output records further reflected a urinary output of only 425 cc during the entire five-day period prior to her acute hospitalization on [DATE], while the nursing notes for this same time frame documented that the urinary catheter was "patent" (unobstructed) and draining yellow urine into the bedside drainage bag. There was no evidence the resident's decreased urinary output was communicated to a licensed nurse, nor was there evidence that a licensed nurse assessed the resident related to this decreased urinary output until 9:30 p.m. on 08/19/11. There was also no evidence the resident's daily fluid intake had been compared to her daily urinary output to identify a fluid imbalance, nor was there evidence to show staff notified the physician of the resident's poor urinary output over the five-day period preceding her acute hospitalization . The resident was transferred to the hospital emergency room (ER) on 08/19/11, where the ER physician noted on the early morning of 08/20/11 (quoted as typed): "... this is the worst looking foley cath i have ever seen. with the tip of the catheter was almost completely occluded causing the patient [MEDICAL CONDITION] and causing pus to leak out around the foley filling the patients diaper. Pt (patient) smelt horrible. 1400 cc obtained after the Foley was changed. ..." The lack of assessment / monitoring the use of the catheter, and failure to identify of the dysfunction of this urinary catheter, resulted in this resident being transferred to the ER and admitted to the hospital for further treatment due to [MEDICAL CONDITION]. This practice resulted in actual harm to one (1) of six (6) sampled residents and presented the potential for more than minimal harm was identified for three (3) of three (3) residents currently residing in the facility with indwelling urinary catheters that require monitoring. Resident identifiers: #157, #66, #84, and #20. Facility census: 156. Findings include: a) Resident #157 Review of Resident #157's medical record revealed this [AGE] year old female was admitted to the facility on [DATE]. She had previously been a patient multiple times in the hospital and in an acute rehabilitation facility, but after she experienced a decline in her condition, she was transferred to this facility. The resident had experienced a fluctuation in body temperature from the time she was admitted to this facility. The hospital had evaluated this and recorded that she had a fever of unknown origin. She had multiple tests and procedures to identify the cause of these temperature changes, but the reason for them was not identified. The medical record revealed that, in the past (prior to her admission to this facility), she had required intermittent catheterization due to [MEDICAL CONDITION] and she had chronic problems with urinary tract infections. She continued to require intermittent catheterization after her admission to the facility due to [MEDICAL CONDITION]. She had multiple medical [DIAGNOSES REDACTED]. This resident was nonverbal and required total care from the staff, including transfers with a mechanical lift. Upon her initial admission to this facility, she had an elevated temperature, and she was sent to the hospital on two (2) occasions since her admission on 06/24/11. She was exhibiting poor oral intake of food and fluids, and recommendations were made for a feeding tube. The facility had notified the family and they were waiting on the family to call them back with permission to proceed with having the feeding tube inserted as of 08/18/11, when she was transferred to the hospital. She was a full code, and it was expressed on her physician orders [REDACTED]. - The physician's monthly recapitulation orders for August 2011 contained the following orders: - 07/18/11 - "Change bedside drainage bag when occluded or when foley catheter is changed. *schedule needed* - PRN." - 07/18/11 - "Change Foley Catheter when occluded, leaking, or as needed. *schedule needed* - PRN." - 07/18/11- "Foley catheter 16 FR with 5-10cc balloon to bedside straight drainage for [DIAGNOSES REDACTED]. - 07/18/11- "Foley catheter care." - A review of the nursing note entries related to the indwelling urinary catheter (quoted as typed): - 08/12/11 at 5:22 p.m. - "... f/c (Foley catheter) patent and draining to bedside draingae bag ..." - 08/13/11 at 2:14 a.m. - "... foley patent draining yellow urine into bedside drainage bag." - 08/13/11 at 1:47 p.m. - "... foly cath that it patent and draining to bed side drainage bag ..." - 08/14/11 at 3:20 a.m. - "... foley cath patent draining yellow urine into BSDB (bedside drainage bag). ..." - 08/15/11 at 3:51 p.m. - "... has foley cath , patient and draining yellow urine into BSDS (bedside drainage system) ..." - 08/16/11 at 10:48 a.m. - "... foley cath patient and draining yellow urine to BSDB. ..." - 08/17/11 - (There were no nursing notes written for this resident on 08/17/11.) - 08/18/11 at 1:56 p.m. - "... foley patient and draining yellow urine to BSDB..." - 08/19/11 at 3:56 a.m. - "... foley cath patent draining yellow urine to BSDB..." - 08/19/11 at 11:27 a.m. - "P.C. (phone call) to (name) P.O.A. (power of attorney) of (Resident #157), unable to reach left her message on cell phone re: (regarding) possible [DEVICE], did not mention resident's name." - 08/19/11 at 9:30 p.m. (Late Entry) - "Notified of elevated temp 102.2 and pulse 140. Bowel sounds absent and abdomen hard and extended. Resident had no urine in BSDB and 3p-11p cna (certified nursing assistant) stated it wasn't emptied throughout her shift. Hydration protocol not completed by 7a-7p nurse and was left blank. Dr. (name) notified and t/o (telephone order) to send to (name of hospital) for evaluation. Notified POA of transfer." - 08/19/11 at 9:58 p.m. - "(Resident #157) transferred to hospital-unplanned for evaluation and treatment ... Res (resident) febrile w/ (with) elevated pulse rate. Abdomen hard t/t. x 4qds (quadrants) absent of Bowel sounds. ..." There was no evidence recorded in any of the nursing notes leading up to the resident's acute transfer of any abnormal findings concerning the urinary catheter or the resident's urinary output. - The resident was transferred to the hospital emergency room (ER) on 08/19/11, where the ER physician recorded the following in the clinical report on the early morning of 08/20/11 (quoted as typed): "... this is the worst looking foley cath i have ever seen. with the tip of the catheter was almost completely occluded causing the patient [MEDICAL CONDITION] and causing pus to leak out around the foley filling the patients diaper. Pt (patient) smelt horrible. 1400 cc obtained after the Foley was changed. ..." - A review of fluid intake and output records for Resident #157 found the following information about her urinary output (recorded per shift) on the days leading up to her acute hospitalization : On 08/19/11 - 11 to 7 shift - 0 cc - 7 to 3 shift - 50 cc - 3 to 11 shift - 0 cc 24-hour total = 50 cc On 08/18/11 - 11 to 7 shift - 0 cc - 7 to 3 shift - 0 cc - 3 to 11 shift - blank (nothing recorded) 24-hour total = 0 cc On 08/17/11 - 11 to 7 shift - blank (nothing recorded) - 7 to 3 shift - 0 cc - 3 to 11 shift - 0 cc 24-hour total = 0 cc On 08/16/11 - 11 to 7 shift - 0 cc - 7 to 3 shift - 50 cc - 3 to 11 shift - 25 cc 24-hour total = 75 cc On 08/15/11 - 11 to 7 shift - blank (nothing recorded) - 7 to 3 shift - 200 cc - 3 to 11 shift - 0 cc 24-hour total = 200 cc On 08/14/11 - 11 to 7 shift - blank (nothing recorded) - 7 to 3 shift - 300 cc - 3 to 11 shift - 200 cc 24-hour total = 500 cc On 08/13/11 - 11 to 7 shift - 200 cc - 7 to 3 shift - 175 cc - 3 to 11 shift - 100 cc 24-hour total = 475 cc - A review of the resident's care plan, dated 07/04/11, revealed there was no plan addressing the care of her indwelling urinary catheter. The resident had a plan that identified her risk for [MEDICAL CONDITION] which required intermittent catheterization. This plan, dated 07/18/11, directed staff to assess the resident for bladder distention and to monitor her urinary output for color, consistency, and amount. There was no evidence this was done or that interventions were added when an indwelling catheter was inserted, to prevent complications of its use. - During an interview on 10/25/11 at 10:00 a.m., the director of nursing (DON - Employee #127) verified the facility had identified some issues related to communication of the residents' urinary output and the monitoring of the catheters. She also verified staff inservicing had been conducted, a new form had been implemented for measuring urinary output, and nurses had been suspended for not assessing this resident's urinary output. The DON stated the nurses were to review and initial this new output form each shift to verify they reviewed it. (Review of the form found a box for recording the nurse's initials.) She also verified that, at this facility, nurses worked 12-hour shifts and nursing assistants worked 8-hour shifts, so there should be initials from three (3) nursing assistants and two (2) nurses on this form daily. - A review of the new catheter care and output documentation, which was implemented as a result of the nurses failing to assess the urinary outputs of residents with catheters, found these new forms were not being completed and checked by the nurses as instructed. Failure to monitor a resident's output urinary daily could result in any dysfunction of the catheter going undetected. The records of three (3) residents with indwelling urinary catheters present were reviewed for these new output records: 1. Resident #20 This resident was identified as having an indwelling urinary catheter. Record review revealed he had a newly implemented catheter care and output record, where the nursing assistants were to record the resident's urinary output and document having completed catheter care each shift. Of the twenty (20) days reviewed, three (3) shifts had no urinary output recorded. Seventeen (17) days had no evidence that two (2) nurses reviewed this resident's urinary output. Five (5) days had no evidence that this resident's urinary output was reviewed by even one (1) nurse. This review found this new output form was not being completed as intended, to reflect daily monitoring of the resident's urinary output and assure the indwelling catheter was functioning properly. - 2. Resident #84 This resident was identified as having an indwelling urinary catheter. Record review revealed she had a newly implemented catheter care and output record, where the nursing assistants were to record the resident's urinary output and document having completed catheter care each shift. Of the twenty-five (25) days reviewed, three (3) shifts had no urinary output recorded. Twenty-one (21) days had no evidence that two (2) nurses reviewed this resident's urinary output. Nine (9) days had no evidence that this resident's urinary output was reviewed by even one (1) nurse. This review found this new output form was not being completed as intended, to reflect daily monitoring of the resident's urinary output and assure the indwelling catheter was functioning properly. - 3. Resident #66 This resident was identified as having an indwelling urinary catheter. Record review revealed he had a newly implemented catheter care and output record, where the nursing assistants were to record the resident's urinary output and document having completed catheter care each shift. Of the five (5) days reviewed, one (1) shift had no urinary output recorded and was not initialed by a nursing assistant. There was also no evidence that a nurse reviewed the resident's urinary output for this shift or further assessed the reason for the blanks. - During an interview on 10/26/11 at 2:30 p.m., the unit manager (Employee #95) verified she was aware that the forms were no always being completed. She verified there were blanks on the forms where the aides failed to record the urinary output each shift and blanks where the nurses failed to initial the boxes to verify they had reviewed each resident's urinary output on each shift. .