Every finding on record at Idaho State Veterans Home - Lewiston

Based on record review, staff interview, and facility policy, it was determined the facility failed to ensure residents were free from accidents. This was true for 1 of 1 resident (Resident #2) whose record was reviewed for avoidable falls. This failure resulted in harm to Resident #2 when the facility did not provide care in accordance with the plan of care and failed to maintain his safety. Findings include:A request was made for the facility's incident and accident policy; however, the facility provided a Resident Incident Report and a Resident Incident/Accident Report Procedure Guide.Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including displaced fracture of the second cervical vertebra, vertigo, and dementia.A review of Resident #2's care plan dated 3/29/21, documented the following transfer methods initiated on 6/2/21: transfer extensive assist with two people; transfer limited assist with one person; transfer supervision or cueing assistance with one person; transfer extensive assist with one person; and transfer extensive assist with one person using a gait belt.A comprehensive Minimum Data Set (MDS) assessment dated [DATE], documented Resident #2 required substantial/maximal assistance for sit to stand transfers and partial/moderate assistance for bed to chair transfers.A review of the facility's incident and accident report dated 5/2/26 at 2:30 PM documented, Resident #2 sustained a witnessed fall. The report documented that Resident #2 called for assistance to go to the restroom. CNA #4 positioned the wheelchair in front of Resident #2 and ensured the brakes were locked. CNA #4 verified Resident #2 had shoes on and proceeded to assist with the transfer. CNA #4 supported Resident #2's hips as he stood and placed both hands on the left side of the wheelchair. Resident #2 lost his balance, his feet became tangled, and he fell onto his right side.The report documented nursing staff assessed Resident #2 and identified several lacerations, including one on his right cheek, his head, and his right eye. Resident #2 reported pain rated at 15 out of 10. Resident #2 was transported to the emergency room for further evaluation and was later determined to have sustained a cervical spine fracture. Resident #2 was placed in a Miami J neck collar (a type of neck brace) for 12 weeks as he was not a candidate for surgery.On 9/2/26 at 2:35 PM, the DON stated the incident involving Resident #2 was a learning opportunity for the facility. She stated Resident #2's care plan did not match the level of assistance staff were providing at the time of the incident. The DON reported staff were treating Resident #2 as requiring standby supervision, while the care plan documented multiple transfer levels including extensive assist with one person using a gait belt. The DON confirmed Resident #2 was not using a gait belt during the transfer at the time of the incident. She stated the facility updated the procedure and provided education to staff following the incident. The DON acknowledged the facility failed to prevent the incident due to staff not following the care plan.As a result of the facility's investigation, non compliance was identified and the following corrective actions were implemented: all direct care staff were re-trained on transfers and gait belt use between 5/20/26 and 5/26/26. The facility reviewed and revised the Gait Belt for Transfer and Ambulation policy dated 6/2026.The facility was noted to be in substantial compliance as of 6/1/26; therefore, a plan of correction is not required.

Based on observation, the Food Drug Administration (FDA) Food Code, and staff interview, it was determined the facility failed to ensure ice machines were cleaned, and resident freezers did not contain undated food. This deficient practice had the potential to affect the 43 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include:1. The FDA Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, documented marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded.On 8/31/26 at 1:23 PM, two bags of French onions were on the pantry shelves with an expiration date of 5/30/26. A bin of pasta noodles was observed without a label or date.On 8/31/26 at 1:25 PM, the CDM stated that expired food should be thrown away and all food bins should be labeled and dated.2. The FDA Food Code Section 4-602.11 Equipment Food-Contact Surfaces and Utensils, documented surfaces of equipment contacting food that is not time/temperature control for safety, such as ice makers and ice bins that need to be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms.On 8/31/26 at 1:35 PM, the ice machine in the main dining room was observed with yellow and black streaks running down the interior of the ice machine and yellow colored residue on the upper white lip of the white ice separator.On 8/31/26 at 1:37 PM, the CDM stated maintenance had cleaned the ice machine monthly and it was last cleaned on 8/26/26. She did not know why there was discoloration on the interior of the machine.

Based on observation, record review, resident and staff interviews, it was determined the facility failed to serve palatable food to residents who were interviewed about food temperature and taste. This was true for all residents who consume food prepared at the facility. This deficient practice had the potential to create dissatisfaction with meals and decrease residents' quality of life. Findings include:On 8/31/26 at 3:41 PM, Resident #8 stated her in-room meals are never hot, but cold food is cold.On 9/2/26 at 1:33 PM, during a Resident Council meeting with 11 residents in attendance, the residents expressed concerns the food is only warm on rare occasions when it should be hot.Facility grievances dated January 2026 through August 2026, documented concerns with food texture, temperature, and quality which were not to the standards residents and their representatives wanted for their meals.On 9/3/26 at 7:15 AM, a regular tray was observed from initial plating to final destination with the following results:-At 7:35 AM, the dining cart for resident room dining was completed.-At 7:36 AM, the dining cart was moved from the Kitchen to the [NAME] Wing resident hall.-At 7:45 AM, the final resident meal tray was delivered.On 9/3/26 at 7:47 AM, a test tray was reviewed with the following results:-Scrambled eggs: 121 degrees fahrenheit-Cream of wheat hot cereal: 134 degrees fahrenheit-French toast: 116 degrees fahrenheit-Yogurt: 47 degrees fahrenheit-Orange juice: 47 degrees fahrenheit-Milk: 47 degrees fahrenheitA review of the initial hot holding temperatures prior to service documented the following:-Cream of wheat: 196 degrees fahrenheit-French toast: 165 degrees fahrenheit-Yogurt: 36 degrees fahrenheit-Scrambled eggs: 165 degrees fahrenheitThe temperature of the scrambled eggs dropped 44 degrees in 12 minutes.The temperature of the French toast dropped 49 degrees in 12 minutes.The temperature of the yogurt rose 11 degrees in 12 minutes.The palatability of the French toast and scrambled eggs were noted to be slightly warm.The cream of wheat with sugar and butter topping was not palatable.On 9/3/26 at 2:30 PM, the CDM had no explanation why the food temperatures had dropped so much as the food was plated on warm dish plates with heat plate coverings and transported in an appropriate temperature cart. When asked about palatability the CDM stated sugar and butter topping were added for residents' who needed increased calories.

Based on record review and staff interview, it was determined the facility failed to ensure residents were offered the opportunity to implement their advance directive. This was true for 3 of 12 residents (#27, #37, and #38) whose records were reviewed for resident rights. This failure created the potential for poor outcomes if residents did not make their wishes known and were unable to communicate. Findings include:1. Resident #27 was admitted to the facility on [DATE], with multiple diagnoses including acute kidney failure, repeated falls, hearing loss, and depression.Resident #27's record did not include an advanced directive for healthcare.Resident #27's record did not include documentation of resources offered for assistance with formulating an advanced healthcare directive.2. Resident #37 was admitted to the facility on [DATE], with multiple diagnoses including neurocognitive disorder with lewy bodies (a progressive brain disease that causes a decline in thinking, movement, sleep, and behavior), parkinson's disease (a progressive disorder of the nervous system that affects movement and worsens over time), congestive heart failure, post-traumatic stress disorder (PTSD-a mental health condition that can develop after you experience or witness a terrifying or life-threatening event), and major depressive disorder.Resident #37's record did not include an advanced directive for healthcare.Resident #37's record did not include documentation of resources offered for assistance with formulating an advanced healthcare directive.3. Resident #38 was admitted to the facility on [DATE], and re-admitted on [DATE], with multiple diagnoses including parkinson's disease, bipolar disorder, major depressive disorder, and dementia.Resident #38's record did not include an advanced directive for healthcare.Resident #38's record did not include documentation of resources offered for assistance with formulating an advanced healthcare directive.On 9/2/26 at 4:00 PM, the LSW when asked about advanced directives, the LSW stated a Physician Orders for Scope of Treatment (POST-a medical order form that details a person's treatment preferences near the end of life) was an advanced directive. When asked about documentation or education provided to formulate an advanced directive, the LSW stated only the POST was reviewed at care conferences.

Based on record review, policy review, and resident and staff interviews, it was determined the facility failed to notify the physician immediately when a resident experienced a change in condition. This was true for 1 of 4 residents (Resident #8) reviewed for accidents. This deficient practice created the potential for harm when the physician was not promptly notified of Resident #8's wrist pain and irregular pupils following an unwitnessed fall. Findings include:The facility's Documentation/Assessment Recommendations for Residents Experiencing Change in Condition or Acute Illness policy, reviewed 1/25, documented nurses' notes and/or communication about the resident's condition to their primary physician should include, but was not limited to:-Chief Complaint;-Vital Signs;-How long/time frame since change/illness was identified; -Mental Status changes (oriented, alert, confused, comatose, cooperative, lethargic);-Change in functional status (weakness, flaccidity);-Responsiveness (any changes- describe response to pain, eyes open or closed);-Musculoskeletal pain (aching, stabbing, throbbing), location of pain, and history of falls. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including repeated falls, depression, COPD (chronic obstructive pulmonary disease; a long-term lung condition that makes breathing difficult by blocking airflow), diabetes, and kidney disease.On 8/31/26 at 3:41 PM, Resident #8 was observed in her bed with a brace on her left hand. Resident #8 stated she had fallen while brushing her teeth at the sink and hurt her wrist bad enough that it broke. An Incident and Accident (I&A) report, dated 5/19/26, documented Resident #8 experienced an unwitnessed fall at 6:15 AM. The nurse was notified by the night CNA Resident #8 was on the floor, and they had an open area to their left elbow. The RN assessed Resident #8 and noted they were sitting with their back to the wall and closet with their feet pointed towards the ensuite bathroom door. Resident #8 was seated upright with their wheeled walker facing the east wall of the bedroom up against the sink counter. Resident #8 was noted to have a skin tear to the left elbow approximately 1.0 cm x 1.0 cm, with a raised discolored area to the left forearm 1.5 cm x 1.0 cm, with noted raised/swelling to the left wrist. Resident #8 described standing at the sink brushing her teeth when she felt herself go back, falling and hitting her left arm and head.The report further documented the skin tear was cleaned and treated with steri-strips, and covered with telfa (a non-stick pad). Neuro Checks were started. Range of motion was intact, and Resident #8's right pupil was documented to be oblong and not equal to the left pupil on the initial neuro check. The nurse notified the cart nurse of the assessment, and the doctor was notified through the physician communication report.An Physician's communication was written in the physician communication book on 5/19/26, with the following information:-Resident #8: Unwitnessed fall at 6:15 AM with skin tear to left elbow, raised area to left forearm, raised areas to left wrist.The Neurological Assessment Flowsheet documented the following on 5/19/26:-At 6:15 AM: pupils R - Brisk/L-Brisk (both the right (R) and left (L) pupils react quickly (briskly) to light) -At 6:30 AM: pupils R-Brisk/L-Brisk-At 6:45 AM: right hand grasp stronger than Left hand grasp (no pupil check was completed.)-At 7:00 AM: pupils PERL (pupils equal reactive to light).An Incident Note, dated 5/19/26 at 8:32 AM, documented Resident #8's right pupil was oblong and not equal to the left pupil on initial neuro check. A nursing progress note, dated 5/19/26 at 12:09 PM, documented Resident #8 had complained about increased pain and swelling to her left wrist with decreased range of motion (ROM) despite Tylenol administration. Resident #8 requested an x-ray, and her representative was notified, electing to transport Resident #8 to the hospital.A Secure Communication, dated 5/19/26 at 12:13 PM, documented Resident #8 fell during the morning, hitting her left wrist/hand and causing it to bruise. Resident #8 had very limited ROM and increased pain post Tylenol. Resident #8 was requesting to go the emergency room.An Urgent Care Visit Assessment and Plan, dated 5/20/26, documented Resident #8 had a closed fracture of the left wrist, an injury of the left elbow, and an injury of the head.On 9/2/26 at 11:25 AM, the DON stated RN #5 wrote about Resident #8's fall in the Physician (MD) non-emergent notification book at the time of the incident, but he was not instantly made aware via secure communication until 12:13 PM, when Resident #8 complained of wrist pain and wanted to be taken the emergency room (ER). The DON stated there was no documentation the physician responded to the initial notification or the secure communication.On 9/2/26 at 12:27 PM, RN #5, stated the Physician is regularly notified for non-emergent things in the MD notification book that he checks every Wednesday before rounding with the Residents' and he would have been made aware of Resident #8's fall at that time. When asked why the MD was not immediately notified after the resident's neuro-checks documented unequal wrist strength and irregular pupils, she stated staff believed the pain treatment they provided after the fall was enough to assist the resident.

Based on record review, policy review, review of the State LTC Reporting Portal, and staff interviews, it was determined the facility failed to report allegations of abuse as required. This was true for 2 of 3 residents (#2 and #21) whose records were reviewed for staff to resident interactions. This deficient practice created the potential for harm, as failure to report allegations of abuse prevents timely investigation, delays protective measures, and increases risk that residents may experience continued or escalated mistreatment without intervention. Findings include:The facility's Abuse policy, reviewed 1/25, documented [The Facility] will report allegations of abuse within 2 hours to the State LTC Reporting portal.1. Resident #21 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's, dementia, anxiety, psychotic disorder with delusions, depression, and neurocognitive disorder with Lewy bodies. An Abuse report was uploaded to the State LTC Reporting portal on 4/15/26 at 12:49 PM, documenting an incident which was reported to Administration on 4/14/26 at 10:50 PM. RN #4 reported concerns involving CNA #2's interactions with Resident #21. The report stated CNA #2 told RN #4 that Resident #21's roommate was going to report her for how she spoke to Resident #21. The report also documented CNA #3 informed RN #4 she felt uncomfortable with how CNA #2 was caring for Resident #21. RN #4 documented she received the reports from both CNAs at 9:00 PM on 4/14/26. On 9/3/26 at 11:26 AM, after reviewing the reporting times, the LSW acknowledged the allegation of abuse was not reported within 2 hours as the administration wanted to investigate if the incident had happened. She continued, The report should have been reported to the State by 12:50 AM on 4/15/26, after Administration was notified. Cross Reference F600 2. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including displaced fracture of the second cervical vertebra, vertigo, and dementia. A review of Resident #2's care plan dated 3/29/21 documented multiple transfer methods initiated on 6/2/21 including extensive assist with two persons, limited assist with one person, supervision or cueing assistance with one person (with frequent self transfers), extensive assist with one person, and extensive assist with one person using a gait belt. A comprehensive MDS assessment dated [DATE] documented Resident #2 required substantial/maximal assistance for sit to stand transfers and partial/moderate assistance for bed to chair transfers. A review of the facility's incident and accident report dated 5/2/26 at 2:30 PM documented Resident #2 sustained a witnessed fall. The report documented Resident #2 called for assistance to go to the restroom. CNA #4 positioned the wheelchair in front of Resident #2 and ensured the brakes were locked. CNA #4 verified Resident #2 had shoes on and proceeded with the transfer. CNA #4 supported Resident #2's hips as he stood and placed both hands on the left side of the wheelchair. Resident #2 lost his balance, his feet became tangled, and he fell onto his right side. Nursing staff assessed Resident #2 and identified several lacerations including on the right cheek, head, and right eye. Resident #2 reported pain rated at 15 out of 10. Resident #2 was transported to the emergency room and was later diagnosed with a cervical spine fracture. Resident #2 was placed in a Miami J neck collar for 12 weeks as he was not a candidate for surgery. On 9/3/26 at 4:06 PM, the DON confirmed the incident was not reported to the Long Term Care Reporting Portal as potential neglect.

Based on review of the Resident Assessment Instrument (RAI) Manual, policy review, record review, and staff interviews, it was determined the facility failed to ensure resident's MDS assessments included correct assessment information. This was true for 4 of 12 residents (#3, #4, #7, and #37) whose MDS records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include:The facility's Resident Assessment - Coordination with PASARR Program policy, undated, documented all applicants to the facility will be screened for serious mental disorder or intellectual disability and related conditions in accordance with the State's Medicaid rules for screening. PASARR Level II, is a comprehensive evaluation by the appropriate state-designation authority which determines the appropriate setting for the individual and recommends any specialized services the individuals need. The Social Services Director will be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability for a Level II resident review. The RAI Manual, revised 10/2025 documented section A1500, PASRR (Preadmission Screening and Resident Review), was to be coded yes when a PASRR Level II screening determines a resident had a serious mental illness and/or intellectual disability, or related condition. 1. Resident #37 was admitted to the facility on [DATE], with multiple diagnoses including PTSD, neurocognitive disorder with lewy bodies, major depressive disorder, delusional disorder, and hallucinations. Resident #37's PASRR Level I, dated 11/19/25, documented he had a major mental illness diagnosis of depressive disorders. Resident #37's PASRR Level II, dated 11/25/25, documented he had a current diagnosis of severe mental illness per PASRR criteria of major depressive disorder, and delusional disorder. Resident #37's Annual MDS assessment dated [DATE] at A1500, Is the resident currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?, documented the answer no. On 9/2/26 at 4:35 PM, the MDS Coordinator confirmed Resident #37 had a mental illness and further stated the MDS Assessment should have been coded as yes. 2. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's, dementia, diabetes, PTSD, bipolar, depression, and anxiety. Resident #3's medical record documented a PASRR Level II was completed on 11/14/25. The MDS Annual Assessment, dated 7/19/26, marked No at A1500, does the resident have a PASSR Level II evaluation. On 9/2/26 at 4:39 PM, the MDS Coordinator stated, Resident #3 does have a PASSR Level II, and I marked No at A1500 when it should have been marked Yes. 3. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder, cognitive communication deficit, and dementia. A Comprehensive MDS assessment dated [DATE], documented under Section M0300E1 that Resident #7 had one unstageable pressure ulcer or injury due to a non-removable dressing or device. On 9/3/26 at 2:10 PM, the Director of Nursing (DON) stated Resident #7 acquired an unstageable ulcer during a period when he had influenza and did not get out of bed. She stated Resident #7 positioned his left foot outward, applying pressure to the left lateral ankle. The DON stated staff attempted to implement interventions; however, Resident #7 continued to be non-compliant. On 9/3/26 at 2:38 PM, after reviewing Resident #7's MDS assessment, the MDS Coordinator stated Resident #7's assessment was inaccurate and confirmed he did not have an unstageable pressure ulcer due to a non-removable dressing or device.

Based on record review, policy review, and staff interview, it was determined the facility failed to submit a required PASRR Level II evaluation to the State designated PASRR authority. This was true for 1 of 5 residents (Resident #34) reviewed for PASRR documentation. This deficient practice created the potential for harm if Resident #34 did not receive mental health services appropriate to their diagnosed condition. Findings include:The facility's Resident Assessment - Coordination with PASRR Program policy (undated) documented that all applicants must be screened for serious mental illness, intellectual disability, or related conditions in accordance with Idaho Medicaid PASRR rules. The policy further documented:-PASRR Level II is a comprehensive State evaluation to determine the appropriate placement and need for specialized services.-The Social Services Director is responsible for tracking each resident's PASRR status and ensuring referrals are made.-Any resident who exhibits a newly evident or possible serious mental disorder must be promptly referred to the State for Level II review.Resident #34 was admitted to the facility on [DATE], with multiple diagnoses including PTSD.A review of Resident #34's PASRR Level I dated 7/6/22, documented No under box 1 Does the individual have any of the following Major Mental illnesses (MMI)?Resident #34's medical record did not include a PASRR Level II.On 9/2/26 at 3:34 PM, the LSW stated a PASRR Level II needed to be completed for Resident #34 as there was none on file.

Based on policy review, record review, and staff interviews, it was determined the facility failed to ensure that the PASRR Level I/Level II information was updated when there was a change in diagnosis and/or treatment. This was true for 2 of 5 residents (#21 and #37) reviewed for PASRR. This deficient practice created the potential for adverse outcomes when the facility did not notify the state PASRR authority or obtain updated PASRR determinations after new mental health related diagnoses and treatment were identified, resulting in inaccurate and incomplete PASRR information used to guide resident assessment and care planning. Findings include:The facility's Resident Assessment - Coordination with PASARR Program policy, undated, documented all applicants to the facility will be screen for serious mental disorder or intellectual disability and related conditions in accordance with the State's Medicaid rules for screening. PASARR level II, is a comprehensive evaluation by the appropriate state-designation authority which determines the appropriate setting for the individual and recommends any specialized services the individuals need. The Social Services Director will be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability for a level II resident review. 1. Resident #37 was admitted to the facility on [DATE], with multiple diagnoses including PTSD, neurocognitive disorder with lewy bodies, major depressive disorder, delusional disorder, and hallucinations. A review of Resident #37's medical record documented Resident #37 had a diagnosis of PTSD. A review of Resident #37's physician orders dated 4/15/26, documented the provider ordered prazosin (a medication used to treat nightmares related to PTSD) oral capsule 2 mg by mouth at bedtime related to PTSD. A review of Resident #37's PASRR showed the most recent PASRR screen was completed on 1/9/26 prior to the addition of the new medication. There was no evidence the facility notified the state mental health authority or completed a new PASRR evaluation following Resident #37's change in mental condition and treatment. On 9/2/26 at 3:49 PM, the LSW stated Resident #37 started on prazosin on 4/15/26 and should have had another PASRR done. The LSW confirmed Resident #37's current PASRR did not reflect his diagnosis of PTSD and should have had another PASRR done. 2. Resident #21 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's, dementia, anxiety, psychotic disorder with delusions, depression, and neurocognitive disorder with Lewy bodies. Resident #21's medical record documented the following PASSRs had been completed: -PASSR Level I- Depressive Disorders with medication, dated 12/14/17. -PASSR Level 1.5, dated 12/15/17- further evaluation required. Resident #21 was diagnosed with the following during his stay at the facility: -Anxiety, dated 6/8/20. -MDD (Major Depression), dated 6/9/20. -Dementia, dated 4/23/25. -Psychotic disorder with delusions, dated 5/4/26. On 9/2/26 at 3:42 PM, the LSW stated a new PASRR would be completed whenever a resident had a new mental health diagnosis. On 9/3/26 at 10:22 AM, the LSW stated there were no updated PASRRs related to the new mental health diagnoses in June 2020, April 2025, or May 2026, and new ones should have been completed and submitted.

Based on record review, staff interview, and policy review, it was determined the facility failed to implement a comprehensive person-centered care plan for 2 of 12 residents (Residents #7 and #37) whose records were reviewed for the development of a comprehensive person-centered care plan. This failure created the potential for harm when Resident #7 did not have care-planned interventions to prevent his pressure ulcer from worsening and when Resident #37 did not have a developed care plan for post-traumatic stress disorder (PTSD) and pain. Findings include: The facility's Resident Care Planning policy, undated, documented the licensed nurse will update resident care plans as new physician orders are received and when new problems are identified. 1. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including major depressive disorder, cognitive communication deficit, and dementia. A physician order dated 2/26/26, documented Resident #7 was to have the following treatment: Cleanse left lateral ankle with normal saline and gauze, apply anasept gel to the wound bed, apply skin prep to the wound edges, and cover with a 3x3 mepilex dressing. A review of Resident #7's care plan dated 8/24/26, documented Resident #7 had impaired skin integrity. The care plan included interventions such as assessing and documenting wound findings, keeping the dressing clean, dry, and dated, monitoring nutrition and hydration, offloading pressure from the left lateral ankle and fifth toe, providing wound care according to provider order, and repositioning routinely to avoid pressure on the affected area. On 9/2/26 at 2:28 PM, the Director of Nursing (DON) confirmed Resident #7 developed a facility-acquired pressure ulcer identified on 2/26/26. She confirmed Resident #7's care plan addressing pressure ulcer interventions was not developed until 8/24/26, almost six months later. Prior to that date, Resident #7 did not have a care plan developed for pressure ulcer prevention or treatment. The DON provided additional documentation of interventions implemented during that period but confirmed none of those interventions were documented on the care plan. 2a. Resident #37 was admitted to the facility on [DATE] with multiple diagnoses including PTSD, neurocognitive disorder with lewy bodies, major depressive disorder, delusional disorder, and hallucinations. Resident #37's care plan dated xx/xx/xx, did not identify he had PTSD. On 9/3/26 at 3:50 PM, the LSW stated Resident #37's care plan did not include PTSD. The LSW further stated Resident #37 was started on prazosin for night terrors related to PTSD on 4/15/26 and that night terrors were a trigger for Resident #37. b. Resident #37's medical record documented the following physician orders: -Oxycodone oral tablet 5 mg: give 0.5 tablet by mouth in the morning for pain-dated 4/22/26. -Oxycodone oral tablet 5 mg: give 0.5 tablet by mouth every 20 hours as needed for pain-dated 4/22/26. -Naloxone nasal liquid 4 mg/0.1 mL: 1 spray in nostril every 3 minutes as needed for suspected narcotic overdose. Give first dose in either nostril, wait 3 minutes for response, if resident does not wake up administer 2nd dose. Notify MD- dated 8/5/25. -Naproxen oral table: Give 220 mg by mouth every 12 hours as needed for pain- dated 8/12/26. -Acetaminophen oral tablet: Give 1000 mg by mouth three times a day for chronic pain control Not to exceed 3000 mg of acetaminophen in 24 hours from all sources-dated 8/13/25. -Indicate non-pharmacological interventions attempted prior to PRN pain medication administration. 1=repositioning, 2-reduced stimuli, 3=warm blanket, 4=relaxation techniques, 5=distraction, 6=music, 7=massage, 8=other (document other in a progress note). R=Refusal of interventions 0=no PRN's used this shift as needed-dated 11/21/24. A review of Resident #37's care plan did not include a plan of care for pain. On 9/3/26 at 4:03 PM, when asked what interventions were in place for Resident #37's pain, the DON stated she did not see any interventions for pain. The DON further stated if a resident is taking a medication, the diagnosis for that medication should be on the care plan.

Based on record review, staff interview, and policy review, it was determined the facility failed to ensure comprehensive person-centered care plans were revised to reflect current care needs. This was true for 2 of 12 residents (#4 and #8) whose records were reviewed for care plan revisions. This failure created the potential for poor quality of care if staff did not know what care needs Resident #4 and Resident #8 had. Findings include:The facility's Resident Care Planning policy, undated, documented that between interdisciplinary team meetings each discipline will update the resident's care plan as needed.1. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including presence of artificial knee joint, dementia, and heart failure. On 8/31/26 and again on 9/3/26, Resident #4 was observed lying in bed with a hand brace applied to the right hand and a wedge positioned to offload his body from one side to the other. A review of Resident #4's record documented the following physician order for treatment of the right hand initiated 5/29/25: right hand contracture of the 4th and 5th fingers, warm water bath and gentle stretch until end range, cleaning and inspection of the hand, and brace applied to the right hand as tolerated. Resident #4's record did not include a physician order for the application of a wedge for offloading. A review of Resident #4's care plan did not include the application of the right hand brace or the use of a wedge for offloading or repositioning. On 9/3/26 at 2:00 PM, the DON confirmed Resident #4's care plan was not revised to reflect the use of the hand brace or the wedge. She stated she was not aware that Resident #4 was using a wedge and acknowledged that therapy had not evaluated the resident for appropriate use of the wedge. 2. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including repeated falls, depression, COPD, diabetes, and kidney disease. Physician's orders dated 5/12/26, documented Resident #8 was prescribed Aspirin Oral tablet, give 81 mg by mouth in the morning for prevention. A review of Resident #8 care plan did not include information related to which prevention conditions Aspirin was being offered for. On 9/3/26 at 3:17 PM, the DON confirmed Resident #8's care plan did not include stroke prevention, which is why Aspirin was being prescribed, and it should have been updated.

Based on policy review, record review, and staff interviews, it was determined the facility failed to ensure monitoring for potential opioid side effects. This was true for 2 of 6 residents (#8 and #37) reviewed for opioid medications. This deficient practice created the potential for adverse outcomes when the facility did not document assessments for opioid-related adverse effects such as sedation, constipation, or respiratory changes. This resulted in incomplete monitoring to ensure the safe and effective use of opioid medications. Findings include:The facility's Opioid Overdose/Naloxone Management policy, undated, documented: Recognizing the signs of overdose and quickly responding can prevent brain injury and death. The facility will train all staff to recognize the signs of opioid overdose, and if the resident exhibits any of the following overdose symptoms will call 911, initiate basic life support, if indicated, and administer naloxone as per facility protocol and manufacturer's instructions while keeping in mind each route of administration varies in effective response times. Overdose symptoms include: Extremely pale face or clammy to the touch, limp body, blue or purplish color to fingernails or lips, vomiting or making gurgling noises, inability to awaken or speak, and/or breathing or heartbeat slows or stops. 1. Resident #37 was admitted to the facility on [DATE], with multiple diagnoses including PTSD, neurocognitive disorder with lewy bodies, major depressive disorder, delusional disorder, and hallucinations. Resident #37's medical record documented the following physician orders: -Oxycodone oral tablet 5 mg: give 0.5 tablet by mouth in the morning for pain, dated 4/22/26 -Oxycodone oral tablet 5 mg: give 0.5 tablet by mouth every 20 hours as needed for pain, dated 4/22/26 -Naloxone nasal liquid 4 mg/0.1 mL: 1 spray in nostril every 3 minutes as needed for suspected narcotic overdose. Give first dose in either nostril, wait 3 minutes for response, if resident does not wake up administer 2nd dose. Notify MD, dated 8/5/25 -Naproxen oral tablet: Give 220 mg by mouth every 12 hours as needed for pain, dated 8/12/26 -Acetaminophen oral tablet: Give 1000 mg by mouth three times a day for chronic pain control Not to exceed 3000 mg of acetaminophen in 24 hours from all sources-dated 8/13/25 -Indicate non-pharmacological interventions attempted prior to PRN (as needed) pain medication administration. 1=repositioning, 2-reduced stimuli, 3=warm blanket, 4=relaxation techniques, 5=distraction, 6=music, 7=massage, 8=other (document other in a progress note). R=Refusal of interventions 0=no PRN's used this shift as needed-dated 11/21/24. Resident #37's August 2026 MAR/TAR documented Resident #37 was administered Oxycodone oral tablet 5 mg half tablet every morning for pain and Acetaminophen 1000 mg three times a day for chronic pain control. Pain monitors were documented every shift and non pharmacological interventions were attempted as needed. There was no documentation in Resident #37's record for opioid side effect monitors. 2. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including repeated falls, depression, COPD, diabetes, and kidney disease. Physician's orders documented Resident #8 was prescribed oxycodone (an opioid pain medication), HCL oral tablet 5 mg, give 1 tablet by mouth every 6 hours as needed for pain, dated 6/10/26. Resident #8's medical record did not include opioid side effect monitors. On 9/2/26 at 10:33 AM, the DON and RN Manager stated the facility does not have opioid monitoring, there are only monitors for pain and/or non-pharmacological interventions.

Based on observation, policy review, and staff interviews, it was determined the facility failed to ensure staff consistently adhered to acceptable hand hygiene practices. This was true for medication administration observations and true for 1 of 12 residents (Resident #7) observed for infection control. This deficient practice placed residents at increased risk for transmission of infectious agents and adverse health outcomes. Findings include: The facility's Hand Hygiene policy reviewed 03/2025 documented the following:Hand hygiene technique when using an alcohol-based hand rub:-Apply to palm of one hand the amount of product recommended by the manufacturer.-Rub hands together, covering all surfaces of hands and fingers until hands feel dry.-This should take about 20 seconds.Hand hygiene technique when using soap and water:-Wet hands with water. Avoid using hot water to prevent drying of skin.-Apply to hands the amount of soap recommended by the manufacturer.-Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers.-Rinse hands with water.-Dry thoroughly with a single-use towel.-Use clean towel to turn off the faucet.Additional considerations:-The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. 1. On 9/3/26 at 7:37 AM, RN #1 was observed preparing Resident #38's morning medications at the medication cart. RN #1 locked the computer screen and the medication cart and walked to Resident #38's room. RN #1 knocked and entered Resident #38's room. No hand hygiene was observed. RN #1 handed Resident #38 a cup of prepared Lactaid (dietary supplements designed for people with lactose intolerance), water, and discussed with Resident #38 re-checking blood pressure. RN #1 went to the sink in Resident #38's room, pumped soap into his hand, turned on the sink, and quickly performed hand hygiene for 2 seconds. RN #1 then shut the sink off, dried his hands, and exited Resident #38's room. RN #1 obtained the vitals cart in the hallway and returned to Resident 38's room, knocked and entered the room. RN #1 took Resident 38's vitals, obtained a pair of gloves upon exiting the room and returned to the medication cart. RN #1 then donned the gloves, used the keys to unlock the medication cart, and obtained a disinfectant wipe from the medication cart. RN #1 wiped down the vitals cart, discarded the disinfectant wipe and gloves into the trash and entered Resident #38's vital sign results into the computer. No hand hygiene was observed after removing the gloves. RN #1 then prepared the rest of Resident 38's medications, donned gloves, and removed a nasal spray bottle from a box inside the medication cart. RN #1 then locked the medication cart, obtained medications from the top of the cart and walked to Resident #38's room. RN #1 knocked with the gloves on and entered Resident #38's room. RN #1 provided instructions for administering the nasal spray and Resident #38 administered the nasal spray, and took his oral medications. RN #1 exited Resident #38's room with the gloves on and threw away the medication cups in the trash can on the left side of the medication cart. RN #1 placed the nasal spray on top of the medication cart, obtained keys from his arm, and opened the medication cart. RN #1 obtained a disinfectant wipe and wiped down the nasal spray bottle, placed the bottle back in the box inside the medication cart, removed the gloves and performed hand hygiene. On 9/3/26 at 8:36 AM, RN #1 was asked about hand hygiene. RN #1 stated hand hygiene should be performed before going in and out of the rooms. When asked if RN #1 performed hand hygiene before entering Resident #38's room, RN #1 stated he thought he had performed hand hygiene. RN #1 further stated he washed his hands prior to exiting Resident #38's room and further stated it was not long enough. 2. On 9/3/26 at 9:57 AM, RN #2 was observed preparing Resident #26's morning medications at the medication cart. RN #2 locked the medication cart, obtained applesauce from the cooler and used a spoon to scoop applesauce into the medication cup. RN #2 discarded the rest of the applesauce, obtained the medication from the top of the medication cart, and walked to Resident #26's room. RN #2 knocked with her foot and entered the room. RN #2 administered medications to Resident #26, prepped Resident #26's inhaler and provided instruction on how to use the inhaler. RN #2 obtained gloves and a Kleenex from the wall near Resident #26's bathroom, donned the gloves, obtained eye drops and administered 1 drop to each eye. No hand hygiene was observed prior to donning the gloves to administer the eye drops. On 9/3/26 at 10:15AM, when asked about hand hygiene, RN #2 stated she performs hand hygiene when she returns to the medication cart, before med pass, and upon exiting resident rooms. When asked about hand hygiene before donning gloves, RN #2 stated she did not perform hand hygiene prior to donning gloves before administering the eye drops. On 9/3/26 at 4:10 PM, when asked about hand hygiene for floor staff, the DON stated hand hygiene should be performed after taking off any gloves, prior to donning gloves, and between residents. When asked how long staff should perform hand hygiene, the DON stated staff should perform hand hygiene for at least 20 seconds. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including presence of artificial knee joint, dementia, and heart failure. On 9/1/26 at 9:47 AM, RN #3 and CNA #1 were observed providing peri-care to Resident #7. Upon entering Resident #7's room, CNA #1 was observed coming out of the resident's restroom wearing personal protective equipment. RN #3 entered the room, performed hand hygiene, and applied her personal protective equipment. During this time, CNA #1 removed her outer pair of gloves and was observed wearing a second pair of gloves underneath. CNA #1 and RN #3 approached Resident #7 and informed him of the care they intended to provide. CNA #1 then proceeded to perform peri-care for Resident #7. Upon completion of peri-care, RN #3 informed CNA #1 that Resident #7's brief was on the floor. CNA #1 went to Resident #7's dresser and obtained a clean brief. No glove removal or hand hygiene was observed. CNA #1 handed the clean brief to RN #3 and then assisted with positioning Resident #7 while RN #3 placed the brief. CNA #1 stood next to the bed while RN #3 repositioned Resident #7. On 9/1/26 at 10:14 AM, RN #3 confirmed the facility's only approved double gloving policy is for chemotherapy precautions. She confirmed Resident #7 was not undergoing chemotherapy treatment. RN #3 also stated CNA #1 acknowledged she did not perform hand hygiene when required, and that was why CNA #1 stood by the bed and minimized contact while RN #3 completed the remainder of the care.

Based on record review, staff interview, review of facility procedure and review of the Minimum Data Set (MDS) Resident Assessment Instrument (RAI) procedure, the facility failed to ensure the discharge and/or entry tracking records were complete as required for four (Resident (R)2, R21, R1, R22) of four residents reviewed for hospitalization. This failure had the potential to inaccurately identify a resident as receiving care in the facility after they had been admitted to the hospital, which could affect reimbursement and quality measures.Findings include: 1. Review of R21's admission Record, located in the electronic medical record (EMR) under the Profile tab revealed he was admitted to the facility on [DATE] with diagnoses including stroke, kidney transplant, and vascular dementia. Review of R21's Secure Conversations note dated 06/11/25 and located in the EMR under the Progress Notes tab revealed he was sent to the emergency room (ER). Review of R21's Nursing Note dated 06/13/25 located under the Progress Notes tab of the EMR revealed he was re-admitted to the facility following a hospital stay. Review of R21's MDS tab of the EMR revealed there was a quarterly MDS completed on 04/10/25 and an entry tracking record completed on 06/13/25. There was no evidence of a discharge tracking MDS completed upon his transfer to the hospital. During an interview on 07/17/25 at 10:37 AM, the MDS Coordinator (MDSC) stated her understanding was that a discharge tracking record only needed to be completed for a hospital stay greater than 72 hours. She stated R21 was at the hospital from [DATE] to 06/13/25, so a discharge MDS was not required. She stated she had started to complete the discharge tracking record for R21 as she was not very familiar with the requirements but was told by her preceptor it did not need to be completed. The MDSC was unable to explain why an entry tracking record was completed upon R21's return to the facility. 2. Review of R2's admission Record located under the Profile tab of the EMR, revealed he was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, diabetes, and bipolar disorder. Review of R2's Secure Conversations note dated 07/11/25 and located under the Progress Notes tab of the EMR, revealed he was sent to the ER. Review of R2's Nursing Note dated 07/14/25 revealed he was re-admitted to the facility following a hospital stay. Review of R2's MDS tab of the EMR revealed there was a quarterly MDS assessment on 05/16/25 and an entry tracking record completed on 07/14/25. There was no evidence of a discharge tracking assessment upon his transfer to the hospital. During an interview on 07/17/25 at 10:37 AM, the MDSC stated since R2 was at the hospital from [DATE] to 07/14/25, a discharge tracking record should have been completed. She stated it was overlooked. 3. Review of R1's admission Record located in the Profile tab of the EMR revealed he was admitted to the facility on [DATE]. Review of the EMR Progress Notes tab revealed a note dated 07/03/25 which documented R1 went out to the hospital. A Progress note dated 07/05/25 documented R1 returned to the facility following a stay at the hospital for aspiration pneumonia. Review of R1's MDS tab of the EMR revealed no entry tracking record nor discharge MDS assessment were completed. 4. Review of R22's admission Record located in the Profile tab of the EMR revealed he was admitted to the facility on [DATE]. Review of the EMR Progress Notes tab revealed a note dated 07/05/25 which stated R22 was transferred to the hospital. A Progress note dated 07/09/25 documented R22 was re-admitted from the hospital to the facility. Review of R22's MDS tab of the EMR revealed no discharge MDS assessment was completed. During an interview on 07/17/25 at 10:37 AM, the MDSC stated that she initiated and completed MDS entry tracking records and discharge assessments when a resident was out of the building for 72 hours or more. If a resident was not out for at least 72 hours, the assessments were not done because it was an interrupted stay and not a discharge. The MDSC was unsure of the timeframe for the completion of entry tracking records and discharge MDS assessments but reported she tried to complete them within 72 hours of the event. R1 was out less than 72 hours. R22 went to the hospital, and she had not initiated a discharge MDS until 07/17/25, eight days after he returned from the hospital. During an interview on 07/17/25 at 1:10 PM, the Director of Nursing (DON) reported the expectation of following the Resident Assessment Instrument (RAI) manual. Review of the facility's procedure MDS Resident Assessment Instrument revised January 2025 revealed, The entry tracking record will be completed by the MDS Coordinator and The MDS Coordinator(s) will provide a schedule as to which residents are due, the type of assessment to be done and when the assessments/RAI components re due to assure the facility is maintaining compliance with timeframes. Review of the RAI dated 10/01/24 and located at https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual revealed entry tracking records and discharge MDS assessments were to be completed unless a resident was at the hospital for less than 24 hours and remained under observation (not admitted ). They were to be completed no later than seven calendar days following the entry or discharge.

Based on interview, record review, review of facility procedure and review of the Resident Assessment Instrument (RAI), the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the restraint status of five (Resident (R)20, R32, R3, R5, and R34) of five residents reviewed for restraint use out of a total sample of 18. These failures created a potential for an incomplete or ineffective plan of care related to bedrail/siderail and restraint use.Findings include: 1. Review of R20's undated admission Record located under the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses including heart disease, collapsed vertebra, mood disorder, vascular dementia, depression, and anxiety. Review of R20's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/04/25 and located under the MDS tab of the EMR revealed he was dependent on staff for transfers in and out bed and required substantial to maximum assistance with bed mobility. He used bed rails as a restraint daily. Review of R20's Side Rail assessment dated [DATE] and located under the Assessment tab of the EMR revealed he used left and right turn rails for bed mobility and the rails did not restrict his movement or access to his body. During an interview on 07/16/25 at 12:53 PM, Registered Nurse (RN) 1 stated R20 was dependent for transfers out of bed and used a mechanical lift assisted by two staff members with transfers. RN1 stated the resident used his bed rails to assist with mobility and positioning in bed. RN1 stated the bed rails did not restrain the resident in any way. During an interview on 07/17/25 at 10:37 AM, the MDS Coordinator (MDSC) stated she marked side rails under the restraint section whenever side rails were in use, whether they were considered restraints or not. The MDSC stated it was only a yes or no question related to the use of bedrails, and she was not aware of the requirement to only code a bed rail used as a restraint under this section. The MDSC stated R20 did not use any restraints, and the bed rails were used for assistance with mobility. 2. Review of the undated admission Record in the EMR under the Profile tab revealed R32 had diagnoses including Parkinson's Disease, and dementia with agitation, and anxiety disorder. Review of the quarterly MDS with an ARD of 06/13/25 in the EMR under the MDS tab revealed a BIMS score of nine out of 11 which indicated the resident was moderately impaired in cognition. Under the Physical Restraints and Alarms section, physical restraints were defined as, any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. R32 was coded as using two bed rails as restraints. Review of the Order Summary Report dated 07/25/24 under the Orders tab revealed, Bilateral transfer rails on bed to enhance independence with bed mobility. Review of the quarterly Side Rail assessment dated [DATE] in the EMR under the Assessment tab revealed the bed rails did not restrict the resident's freedom of movement or access to his body. The bed rails (right upper and left upper turn rails) were indicated for support and to enable bed mobility. Recommend left and right upper bed rail. Review of the Care Plan dated 12/10/21 revealed a focus area of altered mobility and risk for falls. The goal was for R32 to have no serious injury related to falls. Interventions in pertinent part included, I utilize 1/4 side rail on the right side of my bed to enhance my independent with bed mobility. Assess me for safety with these devices quarterly and PRN [as needed]. During an interview together on 07/16/25 at 3:08 PM, the Infection Preventionist (IP) and RN3 stated R32 utilized one bar on his bed for turning, the provision of care, and for transferring in and out of bed. Both nurses stated the rail was not a restraint and that R32 could get in and out of bed with the rail in place. 3. Review of R3's undated admission Record located in the Profile tab of the EMR revealed she was re-admitted to the facility on [DATE] with diagnoses of stroke and low back pain. Review of a Bed Rails Informed Consent for Use dated 03/22/24 and located in the Misc tab of the EMR revealed R3 was recommended for use of upper bed rails on her bed. Review of R3's Care Plan tab revealed, I have impaired mobility and require use of upper bilateral side rails for bed mobility assistance revised on 03/22/24. Review of R3's Order Summary Report located in the Orders tab of the EMR revealed an order for bilateral bed rails on the bed to enhance independence with bed mobility. Review of a Side Rail Assessment located in the Assessments tab of the EMR and dated 06/12/25 revealed R3 used left and right upper bed rails for positioning/support and/or to enable bed mobility. The rails did not restrict the resident's freedom of movement or access to their body. Review of R3's quarterly MDS with an ARD of 06/13/25 located in the MDS tab of the EMR revealed a BIMS score of 15 out of 15, which indicated intact cognition. Further review revealed R3 was coded as using bed rails on a daily basis as a physical restraint, restricting freedom of movement or normal access to one's body. 4 Review of R5's admission Record located in the Profile tab of the EMR revealed she was admitted to the facility on [DATE] with diagnoses of Parkinson's disease and weakness. Review of a Bed Rails Informed Consent for Use dated 02/16/21 and located in the Misc tab of the EMR revealed R5 was recommended for use of 1/4 side rails on her bed. Review of R5's Order Summary Report located in the Orders tab of the EMR revealed an order dated 02/16/21 for bilateral side rails for bed mobility and support. Review of R5's Care Plan tab revealed an intervention dated 02/22/21, I utilize bilateral 1/4 side rails to my bed to enhance my independence with bed mobility. Review of a Side Rail Assessment located in the Assessments tab of the EMR and dated 04/30/25 revealed R5 used left and right upper turn rails for positioning/support and/or to enable bed mobility. The rails did not restrict the resident's freedom of movement or access to their body. Review of R5's quarterly MDS with an ARD of 05/01/25 located in the MDS tab of the EMR revealed a BIMS score of 15 out of 15, which indicated intact cognition. Further review revealed R5 was coded as using bed rails on a daily basis as a physical restraint, restricting freedom of movement or normal access to one's body. 5. Review of R34's undated admission Record located in the Profile tab of the EMR revealed he was admitted to the facility on [DATE] and had a diagnosis of a stroke. Review of a Bed Rails Informed Consent for Use dated 10/07/24 and located in the Misc tab of the EMR revealed R34 was recommended for use of bilateral transfer rails on his bed. Review of R34's Order Summary Report located in the Orders tab of the EMR revealed an order dated 10/07/24 for bilateral bed rails to enhance independence with bed mobility. Review of R34's Care Plan tab revealed an intervention dated 10/23/24, I utilize bilateral transfer bars to my bed to enhance my independence with bed mobility. Review of R34's Progress Notes tab of the EMR dated 07/09/25 indicated, does not use his bed, prefers to sleep in his recliner. Review of a Side Rail Assessment located in the Assessments tab of the EMR and dated 07/10/25 revealed R34 used left and right upper turn rails for positioning/support and/or to enable bed mobility. The rails did not restrict the resident's freedom of movement or access to their body. Review of R34's quarterly MDS with an ARD of 07/11/25 located in the MDS tab of the EMR revealed a BIMS score of 13 out of 15, which indicated intact cognition. Further review revealed R34 was coded as using bed rails on a daily basis as a physical restraint, restricting freedom of movement or normal access to one's body. During interview on 07/14/25 at 9:35 AM, R34 reported he slept in his recliner. During an interview on 07/17/25 at 10:37 AM, the MDSC reported R34's MDS was miscoded because he slept in his chair and did not use any bed rails. Review of the facility's procedure titled MDS Resident Assessment Instrument (RAI) dated January 2025 revealed nursing was responsible for Section P (restraints) and the MDSD oversaw the MDS process. Review of the RAI dated 10/01/24 and located at https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual revealed physical restraints were any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. During an interview on 07/17/25 at 1:00 PM, the Director of Nursing (DON) verified the MDS assessment was inaccurate in the area of restraints for R20, R32, R3, R5 and R34. The DON stated she was not aware restraint use was being coded on the MDS when a resident used bedrails, as there were no actual restraints in use in the facility.

Based on observation, interview, record review, and policy review, the facility failed to ensure one out of 18 sampled residents (Resident (R)32) was treated with dignity. R32's catheter bag, attached to his leg, was observed with urine in it for several hours while the resident was in the common areas with multiple residents and staff, and while attending an activity. Staff failed to intervene to ensure the catheter bag was covered. This created the potential for R32 and other residents to feel undignified.Findings include: Review of the facility's policy titled Dignity dated December 2025 and provided by the facility revealed, Each resident of the [facility name] shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Demeaning practices and standards of care that compromise dignity is prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags covered.Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R32 had diagnoses including Parkinson's Disease, and dementia with agitation, anxiety disorder, and obstructive and reflux uropathy (blockage in the urinary tract and/or urine flows backward from the bladder into the ureters).Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/13/25 in the EMR under the MDS tab revealed the resident was moderately impaired in cognition with a Brief Interview for Mental Status (BIMS) score of nine out of 11 which indicated moderate cognitive impairment). R32 utilized an indwelling catheter. R32 required partial/moderate assistance for toileting hygiene, upper body dressing and required substantial/maximal assistance for lower body dressing. Review of the Order Summary Report dated 06/21/25 in the EMR under the Orders tab revealed R32's physician prescribed a Foley catheter. Review of the Care Plan dated 11/16/23 in the EMR under the Care Plan tab revealed R32 had a focus area of, I need limited to extensive assistance in most care areas r/t [related to] Parkinson's disease with impaired mobility, CHF [congestive heart failure] with activity intolerance, dementia. The goal was, I will be clean and well groomed, without odor and will continue to assist with my care as I am able through the review date. Interventions included in pertinent part, Dressing: extensive assist x [times] 1 [one staff] . Review of the Care Plan dated 05/16/25 in the EMR under the Care Plan tab revealed a focus area of, I . have a foley catheter r/t [related to] impaired mobility, Parkinson's disease, CKD [chronic kidney failure], DM II [diabetes mellitus type 2], CHF [Congestive Heart Failure], dementia, medication effects. The goal was, I will remain free from skin breakdown related to incontinence, foley catheter and brief use through the review date. Interventions in pertinent part included, Resident educated on the possibility of people visualizing the catheter when he is in shorts, he states he does not have an issue with this and will continue to wear shorts as preferred.Observation on 07/16/25 at 8:00 AM revealed R32 was propelling through the common area in front of the nursing station and past three residents to go down the East hall. R32 was wearing shorts and had a visible leg bag attached to his left lower leg which was about half full of urine. The catheter bag was clear. There was no dignity bag/cover in place.Observation on 07/16/25 at 9:52 AM revealed R32 was sitting in his wheelchair in the hallway at the entrance to his room. He continued to wear shorts with the catheter bag attached to his left shin with urine in the bag and fully visible to anyone in the hallway. There were residents and staff coming and going down the hall. Continuous observations were made from this time until 10:42 AM.Observation on 07/16/25 at 10:08 AM revealed R32 was sitting in the common area in his wheelchair facing the atrium directly across from the nurses' station, R32 continued to wear shorts with the leg bag attached to his shin with urine visible. There were several staff sitting at the nurses' station facing R32 and a few residents sitting in recliners in the area as well as staff and residents passing through. R32's catheter bag with urine was visible. Observation on 07/16/25 at 10:13 AM revealed the Recreation Assistant (RA) came over to where he was sitting in his wheelchair and asked him if he wanted to play a game, then left. The RA was not observed to make an inquiry regarding R32's catheter bag. R32's catheter bag with urine was visible. Observation on 07/16/25 at 10:19 AM revealed Certified Nursing Assistant (CNA)1 in the area facing the resident. Several residents wheeled by R32 and a couple were sitting in recliners in the area. R32's catheter bag with urine was visible. Observation on 07/16/25 at 10:22 AM revealed the RA returned to where R32 was sitting and wheeled him into the small sitting area adjacent to the nurses' station. Two more residents arrived at the table where R32 was sitting, and the RA initiated and coordinated a game of Yahtzee with the three residents. R32's catheter bag was visible to anyone in the room, looking in the window into the room or from the doorway. Observation on 07/16/2025 at 10:26 AM revealed all three residents continued to play Yahtzee with the RA. R32's catheter bag was visible to anyone in the room, looking in the window into the room or from the doorway. Observation on 07/16/25 at 10:32 AM, three residents continued playing Yahtzee with activity staff. R32's catheter bag was visible to anyone in the room, looking in the window into the room or from the doorway. Observation on 07/16/25 at 10:42 AM, three residents continued playing Yahtzee with the RA. R32's catheter bag was visible to anyone in the room, looking in the window into the room or from the doorway. Observation on 07/16/25 at 10:50 AM, CNA1 stated that R32's catheter bag with urine was visible as he played Yahtzee with the two other residents and RA. Although CNA1had walked by R32 earlier that morning when he sat at the atrium, she stated she had not noticed his catheter bag was visible with urine. CNA1 stated the bag should be covered with a cloth privacy bag to conceal the urine. CNA1 stated R32 needed a lot more care than he used to and was typically assisted or cued by staff for dressing and toileting. CNA1 stated her assignment included R32's hall and another hall and she was floating between these areas today. CNA1 verified R32's catheter with urine was visible and stated she would put a privacy cover on after the activity was finished. During an interview on 07/16/25 at 11:24 AM, the Director of Nursing (DON) stated the facility had ordered privacy bags for the catheter bags and they had just received a shipment. The DON stated one of these bags would be used to cover R32's catheter bag. During an interview on 07/17/25 at 10:45 AM, the RA stated she had noticed R32's catheter bag was not covered the day before when she assisted R32 to the activity and conducted the activity. The RA stated she asked R32 if he wanted to change into long pants and he declined. The RA stated the uncovered catheter bag with urine in it was a dignity issue for the resident and possibly other residents. During an interview on 07/17/25 at 1:00 PM, the DON stated it was her expectation that catheter bags would be covered in public areas and further stated a catheter bag with urine visible in a public setting was a dignity issue potentially for the resident with the catheter and for other residents who observed it.

Based on policy review, record review, review of the State Survey Agency's Long Term Care Reporting Portal, and resident and staff interview, it was determined the facility failed to ensure residents were free from abuse. This was true for 1 of 12 residents (Resident #25) reviewed for abuse. This deficient practice placed Resident #25 in immediate jeopardy of serious harm, impairment, or death when the facility did not protect him from physical and sexual abuse from Resident #52. Findings include: The facility's Freedom from Resident Abuse, Neglect, Mistreatment & Exploitation Policy, and Procedure, dated 6/2021 documented each resident has the right to be free from verbal, sexual, physical, and mental abuse; neglect, exploitation, mistreatment, including injuries of unknown source misappropriation of resident's property, involuntary seclusion, and crime against a resident. The policy defined the following: Abuse - the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Sexual abuse - is non-consensual sexual contact of any type with a resident. The facility's Social Services Procedure Manual, revised 10/2016, defined sexual abuse as, but not limited to, sexual harassment, sexual coercion, or sexual assault. The manual stated Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the residents. Findings of the examination must be recorded in the resident's medical record. (Note: If sexual abuse is suspected, DO NOT bathe the resident, or wash the resident's clothing or linen. Do not take items from the area in which the incident occurred. Call the police immediately.) - Resident #25 was admitted to the facility on [DATE], with multiple diagnoses including dementia, right hemiplegia, and hemiparesis (paralysis or weakness on one side of the body), neuromuscular dysfunction of bladder (the nerves and muscles don't work together very well), and chronic kidney disease. An annual MDS assessment, dated 4/30/24, documented Resident #25 had moderately impaired cognition and was rarely or never understood. The assessment also documented Resident #25 had a short term and long-term memory problem. - Resident #52 was admitted to the facility on [DATE], with multiple diagnoses including dementia with Lewy bodies (protein deposits develop in nerve cells in the brain causing a decline in mental abilities that gradually gets worse over time) and Parkinson's disease. A quarterly MDS assessment, dated 2/6/24, documented Resident #52 was moderately cognitively impaired. Resident #52's care plan, initiated 4/19/24, documented he had sexually inappropriate behaviors as evidenced by disrobing, fondling himself, making sexually explicit comments and inappropriately touching himself. Resident #25 and Resident #52 were roommates. a. An Investigation Report, dated 5/5/24, documented CNA #1 stated she entered Resident #25 and Resident #52's room to answer their call light. CNA #1 saw Resident #52 on top of Resident #25's bed. Resident #52 was on all fours straddling Resident #25. CNA #1 stated she saw Resident #25's brief on the floor and his catheter had been pulled out. Resident #52 had nothing on from his waist down. CNA #1 stated she did not see Resident #52 pull Resident #25's catheter out, but she knew Resident #25 did not have the strength to remove his own brief or catheter. The report documented CNA #1 reasoned based on the position Resident #52 was in, he had done it to [Resident #25]. CNA #1 reported Resident #25 did not say anything, but he looked wide-eyed and scared. The report documented [Resident #25] had BM [bowel movement] on him from his brief and [Resident #52] had it all over him. After being cleaned up, Resident #52 was moved to another room. The report documented CNA #2 went to Resident #25's room on 5/5/24 at 8:12 AM to get his lunch order. Resident #25 told CNA #2 he wished he was here last night. When Resident #25 was asked why by CNA #2, Resident #25 told him he was molested last night. b. A Late Entry Incident Note, dated 5/5/24 at 2:50 AM, documented Resident #25's roommate had pulled his catheter out. The nurse grabbed the catheter supplies and went to the room. Resident #52 was on his side of the room being cleaned up by staff and Resident #25 was also being cleaned up. The note documented This LN replaced his catheter. The note did not document Resident #25 was assessed for trauma when his indwelling catheter was traumatically removed. c. An Alert Charting Progress Note, dated 5/5/24 at 10:50 AM, documented Resident #25 had blood on his adult brief that was coming from the head of his penis. A Nursing Note, dated 5/5/24 at 11:00 AM, documented a skin check was completed for Resident #25. An abrasion to the tip of his penis was noted, and frank blood (fresh blood) was present. d. A Notice of Emergency Discharge, dated 5/6/24, documented on 5/5/24 Resident #52 was found in state of undress on top of Resident #25. The Notice documented Resident #52 had removed Resident #25's adult brief and forcefully removed Resident #25's catheter causing visible physical harm to Resident #25 as well as psychosocial harm associated with the assault. e. A Progress Note, date 5/6/24 at 9:47 PM, documented Resident #25 had Small amount of frank blood from penis still present. Resident #25's record did not include documentation the physician was notified of the blood on his adult brief that was coming from the head of his penis or presence of the abrasion to the tip of his penis. On 6/25/24 at 2:20 PM, SW #2 stated on the night of 5/5/24, Resident #52 was found on his hands and knees over Resident #25. Resident #25 and Resident #52 were both naked from their waist down. SW #2 stated Resident #52 was moved to a private room that night and placed on a 1:1 supervision. SW #2 stated the facility did not consider Resident #25 was sexually abused by Resident #52 as Resident #52 could not have done anything sexual in the position they were found in. On 6/26/24 at 10:16 AM, Resident #25 stated he remembered an incident with Resident #52. When asked if Resident #52 physically touched him in any other way than removing his brief and indwelling catheter, he shook his head. When asked if he was afraid of anyone in the building, Resident #25 shook his head to indicate no. When asked if he consented to the incident, Resident #25 shook his head. Resident #25 stated he did not want what Resident #52 did to happen. On 6/26/24 at 2:05 PM, during a follow-up interview, Resident #25 stated he had pain when his indwelling catheter was pulled out by Resident #52. On 6/26/24 at 4:05 PM, during a telephone interview, RN #1 stated she was on the other side of the facility with another resident when she was called to Resident #25 and Resident #52's room. RN #1 stated when she entered their room, Resident #25 and Resident #52 were both seated on their side of the room being cleaned by two CNAs. CNA #1 explained to her how she found Resident #25 and Resident #52. RN #1 stated she assessed Resident #25 and re-inserted his indwelling catheter. RN #1 stated I thought the incident was sexual. RN #1 stated there was an abrasion to the groin of Resident #25. On 6/26/24 at 5:50 PM, CNA #1 stated when she entered Resident #25 and Resident #52's room to answer their call light, she saw Resident #52 on top of Resident #25 straddling him. Resident #52 was holding himself up on his hands and knees over Resident #25. CNA #1 stated Resident #25's indwelling catheter and his adult brief were on the floor with bowel excrement (stool). Resident #25 and Resident #52 had stool all over them. CNA #1 stated she told Resident #52 to get off Resident #25, but Resident #52 did not move. CNA #1 stated she stepped to the door and yelled for help then returned to the bedside where Resident #25 and Resident #52 were and asked Resident #52 to get off Resident #25 again, Resident #52 then moved. When CNA #1 was asked what she thought was happening, CNA #1 stated it appeared to be sexual abuse as the residents did not have anything on from their waist down. CNA #1 stated Resident #52 had stool on his hands and Resident #25 had stool all over him. On 6/26/24 at 3:35 PM, when asked what a reasonable person would think if she found the men in the position they were, the DON replied, Some sort of assault had happened or was about to happen. On 6/26/24 at 3:45 PM, the Administrator stated he did not feel this was sexual abuse. On 6/26/24 at 5:05 PM, the Medical Director stated he had been the facility's medical director for [AGE] years. When asked about Resident #25 and Resident #52's incident, the Medical Director stated his gut feeling was more sexual. On 06/27/24 at 4:00 PM, SW #2 stated in regard to interviewing other residents about Resident #52's inappropriate sexual behavior, no, I didn't think it was necessary and didn't think other residents would have anything to contribute. When asked if they might have had something pertinent to share, he stated, I didn't feel they did. Resident #25 was not sent out for a sexual assault examination by a medical provider. There was no documentation in Resident #25's record action was taken to prevent an incident of sexual abuse from happening to other residents. No other residents were interviewed to ensure they were not victims of sexual assault. This failure put all residents in immediate jeopardy for abuse. On 6/26/24 at 8:18 PM, the Administrator and DON were notified of an Immediate Jeopardy (IJ) at F600 related to the facility's failure to ensure Resident #25 was free from sexual abuse. On 6/27/24 at 2:43 PM, the facility provided a plan to remove the immediacy which was accepted. On 6/28/24 at 10:30 AM, the Administrator was notified that the immediacy was removed following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at a G scope and severity following the removal of the immediate jeopardy.

Based on policy review, record review, review of the the State Agency's Long Term Care Reporting Portal, and staff interview, it was determined the facility failed to ensure an allegation of resident abuse was reported to the State Survey Agency within 2 hours. This affected 1 of 12 residents (Resident #25) who were reviewed for abuse. This failure created the potential for residents to be subjected to ongoing abuse without detection and protective measures implemented by the facility. Findings include: The facility's policy titled, Abuse and Neglect Signs and Symptoms of Abuse/Neglect, revised 6/2021, stated The Idaho State Veteran's Home will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing Services immediately. The policy further stated once the allegation was deemed to be reportable by the Abuse Response Team, the social worker reported the alleged violation to the State Long Term Care Agency. The reporting requirement must be met immediately but no later than 2 hours after the allegation is made if the allegation involves actual harm or serious bodily injury. The policy stated if the alleged violation meets the definition of abuse, neglect, exploitation, or mistreatment, the facility should not make an initial determination whether the allegation is credible before reporting the allegation. The State Operations Manual Appendix PP, revised 2/3/23, states In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: -Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made . a. A Facility Reported Incident documented a CNA called this LN to let me know that resident's roommate was naked on top of him in his bed. [Resident #25's] roommate had pulled off [Resident #25's] brief and pulled his catheter out. Staff told his roommate to get off of him. Resident complied within a few minutes. This LN grabbed catheter supplies and went to the room. At this time [Resident #25's] roommate was on his side of the room being assisted/cleaned up by staff. [Resident #25] was also being assisted/cleaned up. This LN replaced his catheter. Residents' roommate was moved to a single room near the nurse's station. The report documented the incident occurred on 5/5/24 at 2:50 AM. The report was submitted to the State Agency's Long Term Care Reporting Portal on 5/5/24 at 11:23 AM, more than 8 hours after the incident occurred. b. A Facility Investigation Summary, dated 5/5/24, documented CNA #2 went to Resident #25's room on 5/5/24 at 8:12 AM to get his lunch order. Resident #25 told CNA #2 he wished CNA #2 was there [at the facility] last night. When Resident #25 was asked why by CNA #2, Resident #25 told him he was molested last night. c. A Notice of Emergency Discharge, dated 5/6/24, documented on 5/5/24 Resident #52 was found in state of undress on top of Resident #25. The Notice documented Resident #52 had removed Resident #25's adult brief and forcefully removed Resident #25's catheter causing visible physical harm to Resident #25 as well as psychosocial harm associated with the assault. d. A fax coversheet, dated 5/5/24, sent by Social Worker SW #2 at 10:30 AM to the local Police Department, included a form titled, Reasonable Suspicion of a Crime Against a Resident Reporting Form. The instructions on the form stated, Contact and submit this completed form to the [State Long Term Care Agency] and local Police Department within 2 hours (if there is serious bodily injury) or 24 hours (if there is not serious bodily injury) of forming a reasonable suspicion that a crime may have been committed against any individual who is a resident of the [facility]. The form included both residents' names and a description of the incident. The form asked, Was there serious bodily injury as a result of the incident? SW #2 marked no in response to the question. A Facility Investigation Summary, dated 5/5/24, and submitted to the State Agency's Long Term Care Reporting portal on 5/8/24, documented 5/5/24 incident between Resident #25 and Resident #52 was described as . resident's roommate was naked on top of him in his bed.roommate had pulled off.brief and pulled.catheter out. The facility's findings were, Information gathered from [Resident #52] along with staff provide clear evidence [Resident #25] was physically abused by his roommate [Resident #52]. [Resident #25's] own statements provide clarity to what [CNA #1] had witnessed and reported. During an interview with SW #2 on 6/25/24 at 1:56 PM, he confirmed he conducted the investigation of the incident on 5/5/24 that occurred between Resident #25 and Resident #52. He stated he did not recollect the events and would need to review his notes of the incident in his own time. When asked about the incident, SW #2 stated, If we knew at the time that it was abuse it might have been a two-hour report. He stated he and the Administrator did not feel the incident resulted in serious bodily injury to Resident #25 and therefore did not have to be reported within two hours but instead within 24 hours. During an interview on 6/25/24 at 2:42 PM, SW #2 and the Administrator stated they (the facility) did not report the allegation withing two hours since there was no serious bodily injury. The Administrator and SW #2 both stated the reporting requirement was 24-hours for abuse when there was no serious bodily injury. When the language in the regulation was explained to state abuse, neglect, misappropriation, or serious bodily harm they both focused on serious bodily harm for reporting in two hours. During an interview with the Administrator on 6/26/24 at 3:45 PM, he stated he did not feel the incident was sexual abuse but could not speak for staff. However, the Administrator stated he felt that there was physical contact.

Based on policy review, record review, review of the State Survey Agency's Long Term Care Reporting Portal, and staff interview, it was determined the facility failed to ensure allegations of abuse were thoroughly investigated. This was true for 1 of 12 residents (Resident #25) reviewed for abuse. This failure placed Resident #25 at risk for the potential of more than minimal harm when the facility did not protect him from physical and sexual abuse from Resident #52. This deficiency also created the potential for all residents residing in the facility to be subjected to ongoing abuse without detection and protective measures implemented by the facility. Findings include: The facility policy titled, Abuse and Neglect Signs and Symptoms of Abuse/Neglect, revised 6/2021, stated Regardless of whether an allegation requires federal or state reporting.all allegations related to abuse (physical, mental, sexual, and verbal), neglect mistreatment, injuries of unknown source.must be thoroughly investigated by the facility under the direction and oversight of the Abuse Response Team, and in accordance with state and federal law. The policy defined the following: Abuse - the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Sexual abuse - is non-consensual sexual contact of any type with a resident. Serious bodily injury - an injury involving extreme physical pain . or an injury resulting from criminal sexual abuse. The policy stated further stated, .steps will be utilized to assist in ensuring a proper, thorough, and impartial investigation is completed timely related to any alleged violation .the allegation is related to abuse, neglect, mistreatment.then Social Services or designee .will take the lead . The policy also stated, 'Any persons who have first-hand knowledge of the incident must submit a signed and dated written statement to the Principal Investigator before they leave the premises at the end of their shift. All statements must include specific times, places, staff/residents, what was said and by whom, and what was seen, in chronological order. - Resident #25 was admitted to the facility on [DATE], with multiple diagnoses including dementia, right hemiplegia, and hemiparesis (paralysis or weakness on one side of the body), neuromuscular dysfunction of bladder (the nerves and muscles don't work together very well), and chronic kidney disease. An annual MDS assessment, dated 4/30/24, documented Resident #25 had moderately impaired cognition and was rarely or never understood. The assessment also documented Resident #25 had a short term and long-term memory problem. - Resident #52 was admitted to the facility on [DATE], with multiple diagnoses including dementia with Lewy bodies (protein deposits develop in nerve cells in the brain causing a decline in mental abilities that gradually gets worse over time) and Parkinson's disease. Resident #52's care plan for behaviors, initiated on 4/19/24, documented Resident #52 had a history of behaviors socially and sexually inappropriate related to dementia and neurocognitive disorder with Lewy bodies. Goals included were to not have Resident #52 harm himself or others and he would have fewer episodes of exposing himself. Interventions also were initiated on 4/19/24 and included anticipating Resident #52's needs, reapproach him if resistive to care, include Resident #52 in an activity program, monitor the number of behavioral episodes. and try to determine the root cause. A second care plan, initiated on 4/19/24, related to Resident #52's sexually inappropriate behaviors. The focus of Resident #52's behaviors was disrobing, fondling himself, sexually explicit comments, and inappropriate touching of himself. The goal was for the behaviors to lessen. The interventions included distraction with activities of preference, offer food or drink, staff were to tell him when his behaviors affected others, monitor, and identify triggers, and staff were to walk away if the behavior persisted. A Facility Reported Incident Summary, dated 5/5/24, did not include times for any the interviews for statements that SW #2 conducted, as directed by the facility policy. The summary documented SW #2 interviewed Resident #25 and Resident #52 on 5/5/24. On 5/7/24 at an unspecified time, SW #2 asked Resident #25 to walk him through what happened on 5/5/24. Resident #25 stated he woke up to a man standing over him handling his indwelling catheter. Resident #25 stated he used his call light for assistance and wished he had something to hit him [Resident #52] with, and that he was afraid. Resident #25 stated he felt unsafe when it happened but after being told Resident #52 was no longer in the facility and would not return, he stated he said good. The summary documented Resident #52 was discharged to the hospital. SW #2 interviewed staff, Resident #25, and Resident #52 as part of his investigation. The investigation did not include interviews with other residents to rule out further allegations and that residents felt safe. During an interview with SW #2 on 6/27/24 at 4:00 PM, he stated he did not think it was necessary to interview other residents and did not think other residents would have anything to contribute. When asked if the residents might have had something pertinent to share, he stated, I didn't feel they did. During an interview with the Administrator on 6/26/24 at 3:45 PM, he stated he did not feel the incident was a sexual incident but could not speak for staff. However, he stated he felt there was physical contact, and staff made Resident #25 and Resident #52 safe, and followed facility policy.

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents were administered the complete pneumococcal vaccine series for 2 of 5 residents (Residents #2 and #4) reviewed for immunizations. This failure resulted in residents having an increased risk of contracting pneumonia. Findings include: The facility's policy for Pneumococcal Vaccinations, dated 4/2022, stated the purpose was to provide residents with the opportunity to receive the Pneumococcal Vaccine in accordance with state and federal guidelines and in accordance with current professional standards. The policy stated it would adhere to the following Pneumococcal Vaccinations Protocol unless directed otherwise by the residents' primary physician. The policy stated, Upon admission to the facility, the residents' medical history will be reviewed to determine evidence of (or lack of) prior pneumococcal vaccination .Should the resident's medical history indicate that the resident has either [not] received the pneumococcal vaccine or has not received the second injection needed to complete the lifetime requirement .an order will be obtained for the vaccine and informed consent obtained .the vaccine is administered .a nursing entry will be made in the nursing progress notes identifying the date, time and site of injection. The vaccine will be recorded in the EMAR [electronic medication administration record] and the Vaccination Record in the electronic medical record. The CDC's document titled Pneumococcal Vaccination: Summary of Who and When to Vaccinate, dated 2/13/23, stated Adults [AGE] years or Older - CDC recommends pneumococcal vaccination for all adults [AGE] years or older. The CDC document stated when no previous pneumococcal vaccine was received, Give 1 dose of PCV [pneumococcal conjugate vaccine] 15 or PCV20. If PCV15 is used, this should be followed by a dose of PPSV [pneumococcal polysaccharide vaccine] 23 at least one year later .If PCV20 is used, a dose of PPSV23 is NOT indicated. The CDC document stated when only PPSV23 was previously received, May give 1 dose of PCV15 or PCV20. The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. The CDC document stated when only PCV13 had previously been received, Give PPSV23 as previously recommended .For adults who have received PCV13 but have not completed their recommended pneumococcal vaccine series with PPSV23, one dose of PCV20 may be used if PPSV23 is not available. If PCV20 is used, their pneumococcal vaccinations are complete. The facility's policy and CDC guidance was not followed. 1. Resident #2's was admitted to the facility on [DATE]. Resident #2 was over the age of 65 at the time of admission. Resident #2's EMR documented Resident #2 had received the PCV13 vaccination on 10/31/19. There was no documentation Resident #2 had received PPSV23 or PCV20. Resident #2's EMR contained an Informed Consent for the PCV20 (Prevnar) vaccine and an Informed Consent for the PPSV23 (Pneumovax) vaccine. Both documents were signed by Resident #2 and facility staff on 11/10/22, indicating Resident #2's consent to receive PCV20 and/or PPSV23. During an interview on 3/16/23 at 10:45 AM, the IP confirmed the facility followed the CDC's guidance for pneumococcal vaccines. The IP stated the Medical Records department helped track vaccinations by pulling a report and the SD staff person helped with obtaining consents. During an interview on 3/16/23 at 1:26 PM, the DNS confirmed Resident #2 had only received the PCV13 vaccination. The DNS stated when she was in the Staff Development position, Medical Records' staff would print a list of who needed what vaccinations. The DNS stated she would then obtain the consents and either she or the IP would input the order. The DNS stated she did not see any documentation as to why Resident #2 had not received the second pneumococcal vaccination. During an interview on 3/16/23 at 1:37 PM, the SD staff person stated the facility needed a better process because residents did not always have vaccination records at admission and it was not always clear which facility staff would follow up on vaccinations. The SD staff person stated that when Resident #2 was admitted to the facility, she (the SD staff person) was new to the position, and she recalled it taking a while for the vaccine to come from pharmacy and Resident #2's vaccine did not get administered. 2. Resident #4 was admitted to the facility on [DATE]. Resident #4 was over the age of 65 at the time of admission. Resident #4's EMR documented Resident #4 had received the PCV13 vaccination on 6/10/21. There was no documentation Resident #4 had received PPSV23 or PCV20. Resident #4's EMR contained Informed Consents for vaccines, as follows: - Informed Consent for PCV13 (Prevnar) Vaccine, dated 12/1/20, which documented the Power of Attorney (POA) gave consent for Resident #4 to receive the vaccination. - Informed Consent for PPSV23 (Pneumovax) Vaccine, dated 12/1/20, which documented the POA gave consent for Resident #4 to receive the vaccination. - Informed Consent for PCV13 (Prevnar) Vaccine, dated 6/3/21, which documented the POA gave consent for Resident #4 to receive the vaccination. During an interview on 3/16/23 at 1:26 PM, the DNS confirmed Resident #4 had only received the PCV13 vaccination. The DNS stated she did not see any documentation as to why Resident #4 did not receive the second pneumococcal vaccination; or had not received the vaccination at the time of admission. The facility failed to ensure Residents #2 and #4 were administered the complete pneumococcal vaccine series.

Based on policy review, staff and resident interview, review of the State Survey Agency's Long-Term Care Reporting Portal, and review of facility documents, it was determined the facility failed to ensure residents were free from verbal abuse, mental abuse, and neglect. This was true for 2 of 15 residents (#4 and #7) who were reviewed for abuse. Resident #7 was subjected to mental and verbal abuse and neglect, when an RN refused to administer her pain and anti-nausea medication until she said please and thank you for the medications. Resident #4 was verbally abused by the same RN when he stated he felt stupid after a verbal interaction with her. These deficient practices placed the health and safety of Resident #4 and Resident #7, and the other 38 residents residing in the facility, in immediate jeopardy of serious harm, impairment, or death. Findings include: The facility's abuse policy, dated June 2021, stated Each resident at Idaho Division of Veterans Services, Idaho State Veterans Home (ISVHs) has the right to be free from exploitation, verbal .and mental abuse .against each resident .and the responsibility of all employees, agents, students, and contractors of the facility (also referenced herein after as to 'covered individuals') to immediately protect the resident(s) and report any and all alleged violations related to abuse, (physical, mental, sexual and verbal) .against a resident .The ISVHs will take all allegations seriously by conducting proper, impartial, and thorough investigations into each alleged violation .Any covered individual who witnesses or suspects abuse (physical, mental, sexual and verbal), neglect, mistreatment .against a resident must ensure the resident(s) is safe and protected from harm . The policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This policy was not followed. The Social Services Procedure Manual, undated, included a section on abuse and neglect which documented examples of the signs and symptoms of neglect and abuse which included the following: - Improper use/administration of medication - Caregiver indifference to resident's personal care and needs - New or more frequent expressions of low self-esteem or self-worth - Anger The procedure manual documented other signs and symptoms of abuse/neglect may be apparent and When in doubt, report it. The procedure manual defined mental abuse was the use of verbal or nonverbal conduct that causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. This procedure manual was not followed. 1. Resident #7 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment, dated 5/19/21, documented Resident #7 was cognitively intact. During an interview on 8/3/21 beginning at 9:37 AM, Resident #7 stated RN #4 told her she had to say please and thank you before RN #4 would administer her medications. Resident #7 stated RN #4 then refused to give her medications and told her she would come back later and walked out of her room. Resident #7 stated RN #4 would not come back to her room and she had to ask another nurse for her medications. When asked what type of medications, Resident #7 stated her pain and anti-nausea medications. Resident #7 stated it happened a couple times and she reported it to a CNA. Resident #7 stated she had talked to the Social Worker about RN #4. Resident #7 stated she had not seen RN #4 for a while and she did not have an issue with the other nurses. The State Survey Agency's Long-Term Care Reporting Portal, from 4/26/21 to 8/2/21, did not include reports for Resident #7. The State Agency's Reporting Portal did include an investigation and documentation of an incident involving a different resident, Resident #4. The documentation from the facility included interviews conducted with staff and residents, including Resident #7, which stated she had filed a grievance about RN #4. There was also documentation from the staff interviews RN #5 had noted a grievance she reported for Resident #7. There was no further information related to Resident #7's concerns about RN #4. The facility's grievances were reviewed from May 2021 to July 2021. Resident #7 had grievances in May 2021 and July 2021. There were no grievances about Resident #7's concerns with RN #4. An interview was conducted with the Social Worker on 8/4/21 at 3:11 PM. The Social Worker stated he reviewed and investigated grievances and he was the abuse investigation coordinator. He stated while he had the title of coordinator allegations were discussed as a group with him, the Administrator, and the DNS. The Social Worker stated while investigating a different allegation of abuse for another resident he learned of the incident between Resident #7 and RN #4. The Social Worker stated after talking to Resident #7, he determined the incident was not reportable therefore, it was not reported to the State Agency, and no investigation was conducted. When asked if the follow up interview was documented, the Social Worker stated yes, and he would gather the information. On 8/4/21 at 10:20 AM, the Administrator provided information related to Resident #7 which was attached to a document titled, Investigation Process Checklist for an allegation which involved Resident #4. The document included emails and witness interviews, as follows: - A typed document had the Social Worker's name at the top and was dated 7/20/21. The document stated while working on an investigation of a complaint for a different resident, Resident #7 stated a while back a nurse had refused to give her medications. Resident #7 stated it was RN #4 when asked which nurse it was. Resident #7 also stated she had reported this to another social worker (who was no longer employed at the time of survey) and they had fixed things and there were no problems since them. The Social Worker documented he spoke with the social worker, who spoke with Resident #7, and she provided him information pertaining to Resident #7's grievance, including a resolution. The document stated the situation was non-reportable to the State Survey Agency. - A typed document had Interview with [Resident #7] at the top and was dated 7/21/21. The document did not include who conducted the interview. The document stated Met with [Resident # 7] for follow-up questions. Resident #7 stated she was speaking with a night shift nurse when she reported a past incident with RN #4 who told Resident #7 she needed to say please and thank you when receiving her medications. Resident #7 stated RN #4 walked out of her room and refused to give Resident #7 her medications. - An email, dated 7/21/21 at 8:04 PM, from RN #5 to the Administrator, DNS, and the Social Worker, stated RN #5 was administering medication to Resident #7 that evening and she shared the Social Worker had come to see her yesterday about RN #4. RN #5 documented Resident #7 told her how RN #4 would come into her room with scheduled medications and said to Resident #7 you will get your medicine when you learn to say please and thank you and walked out of room with my medicine. RN #5 documented she called the Administrator that evening to report this incident and went back to Resident #7's room to write down exactly what was told to her by Resident #7. RN #5 stated Resident #7 was tearful when she went back in to write down what was said by RN #4 to Resident #7. - An email, dated 7/21/21 at 9:34 PM, from RN #1 to the Administrator, DNS, and Social Worker, stated Resident #7 told her yesterday the Social Worker had visited with her about incidents regarding a nurse. The email documented Resident #7 told her how the same nurse, RN #4, had held her medications until she said please and thank you. RN #1 documented after talking with another nurse that day the incident was not reported to the Social Worker like she had thought. During an interview on 8/4/21 at 4:40 PM, the Administrator, with the DNS present, stated residents should not have medication withheld from them. The facility failed to ensure that Resident #7 was free from abuse and neglect. 2. Resident #4 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission MDS assessment, dated 6/29/21, documented Resident #4 had moderate cognitive impairment. The facility entered a report of an allegation of abuse on 7/19/21 at 12:15 PM, to the State Survey Agency's Long-Term Care Reporting Portal. The report documented the incident occurred on 7/18/21 at 2:00 PM, and Resident #4 reported RN #4 was belittling and short with him during cares. The report in the portal documented the staff was removed from the facility pending an investigation. An investigation report completed by the Social Worker, undated, submitted to the State Survey Agency's Long-Term Care Reporting Portal documented Resident #4 made a report on 7/18/21 at 2:00 PM stating He and his nurse [RN #4] had a disagreement with the way he takes his medications and felt the nurse to be rather short with him and made him feel stupid during cares. The investigation included typed witness statements, which documented the following: - A witness statement by CNA #5, dated 7/18/21, stated Resident #10 asked her if nurses were allowed to yell at the residents and belittle them. CNA #5 asked what happened and Resident #10 stated, The .lady nurse yelled at [Resident #4] about his meds. CNA #5 then asked Resident #4 what happened. He explained he's told the nurse numerous times that he only wants milk with his medication. He was then told by the RN that she's new here and can't know everyone. Resident #4 stated he felt like she was talking down to him and made him feel stupid. - A witness statement by CNA #6, dated 7/18/21, stated she heard Resident #10 ask CNA #5 if nurses were allowed to yell at the residents and belittle them. CNA #6 stated [Resident #4] seem [sic] a bit rattled over this. - A witness statement by Resident #10 (Resident #4's significant other), dated 7/19/21, stated, [Resident #4] .reminded the nurse he likes milk with his medication when the nurse sharply told him she's new and can't remember everybody .When asked about [Resident #4's] reaction to this [Resident #10] said he just cowed down with tears in his eyes and didn't say anything. She noted it was very belittling to [Resident #4]. The investigation documented in the conclusion section that Both residents were found to be alert and oriented and to have given a nearly identical account of the exchange during this med [medication] pass. Both have noted RN [RN #4] to be very nice the following day though her actions at the time were found to be sharp, belittling and inappropriate for her profession. During an interview on 8/4/21 at 4:40 PM, the Administrator, with the DNS present, stated the report did not include information whether the allegation was substantiated or unsubstantiated. On 8/4/21 at 10:10 AM, the Administrator provided a letter, dated 7/29/21, which the facility had sent to RN #4. The letter stated RN #4 was involved in an incident concerning abuse/neglect and The Division has conducted an investigation concerning these accusations and found evidence to reflect that this allegation was substantiated. The facility failed to ensure Resident #4 was protected from abuse. On 8/4/21 at 5:04 PM, the Administrator and DNS were notified verbally and in writing of an Immediate Jeopardy (IJ) determination at F600 related to the facility's failure to ensure residents were free from abuse and neglect. This failure placed Resident #7 and Resident #4 at increased likelihood for serious harm, injury, or death, as well as the other 51 residents in the facility. On 8/5/21 at 9:30 AM, the facility Administrator presented a removal plan for the immediacy which was accepted. The removal plan stated the identified staff were immediately placed on leave and staff education regarding abuse, neglect, and facility policy related to reporting began immediately. The removal plan alleged compliance as of 8/4/21 at 5:44 PM. On 8/5/21 at 10:45 AM, the Administrator was notified the immediacy was removed based on onsite verification the IJ removal plan was implemented. Following the removal of the immediacy, noncompliance remained at actual harm which was isolated.

Based on observation, interview, and record review the facility failed to fully implement its COVID-19 prevention plan. The facility failed to ensure infection control standards related to hand hygiene and use of personal protective equipment were implemented and maintained for 8 of 49 residents (R1, R6, R8, R9, R11, R14, R15, and R16). The facility failed to implement appropriate transmission-based precautions during the 14-day period following admission for R1 who admitted with unknown COVID-19 status. The deficient infection control practices placed all residents residing on 3 of 3 halls (North, East, and West) at risk at risk for exposure to and potential for infection with COVID-19 which constituted immediate jeopardy. The facility administration was informed of the immediate Jeopardy on 6/18/20 at 3:05 PM. Findings include: Transmission-based precautions and PPE use During the entrance interview on 6/18/20 at 9:00 AM the Home Administrator (HA) reported all current residents tested negative for COVID-19 and all employees tested negative with re-testing scheduled every two weeks. HA reported this nursing home remained COVID-free but at least two other nursing homes in the community had experienced COVID-19 outbreaks accounting for over 50 cases with some deaths attributed to COVID-19. HA designated the facility Infection Preventionist (IP) and/or the facility Occupational RN-Infection Control Specialist (ICS) to provide facility infection control information. ICS accompanied on initial observations on 6/18/20 at 10:20 AM. ICS said the West Wing (W hall) was the isolation designated hall in the event residents tested positive for COVID-19. A sign posted on resident room W2 door indicated: STOP, Contact Precautions, Please see nurse before entering. The sign did not indicate what personal protective equipment (PPE) or measures were needed to enter the room. When asked what the sign meant ICS said she was new to the building having started a week ago so she did not know specifically what the facility contact precautions were. ICS left briefly and returned with a new sign for room W2. The sign said contact precautions: *perform hand hygiene before enter and before leaving room. *Wear gloves when entering room or cubicle and when touching patient's intact skin, surfaces, or articles in close proximity. *Wear gown when entering room or cubicle and whenever anticipating that clothing will touch patient items or potentially contaminated environmental surfaces. *Use patient dedicated or single-use disposable shared equipment (B/P cuff, thermometer) between patients. ICS said R1 in room W2, admitted from the local hospital on [DATE] and was on contact precautions for 14 days. ICS said new admissions were kept on precautions for 14 days because they may have been exposed to COVID-19 prior to admission and symptoms may not show for up to 14 days. ICS said all residents were tested for COVID-19 on the day of admission, on day 7, and on day 14 and must be negative for COVID-19 after 14 days for precautions to be discontinued. A sign on room E2 indicated Contact Precautions. ISC reported R13 in Room E2 required precautions for 14 days because R13 was a new admission. A sign on room E3 indicated droplet precautions were required. ISC said R8 (in room E3) spiked a fever above 100 degrees Fahrenheit yesterday (6/17/20) and appeared red and flushed (possible symptoms of COVID) so droplet precautions were required for R8 and for R8's roommate (R9) pending the result of a COVID-19 test. Review of the admission nursing note dated 6/17/20 at 5:46 PM indicated Resident R1 came to the facility at 2:14 PM from the local hospital where he was admitted due to increased shortness of breath and fatigue. R1 had [DIAGNOSES REDACTED]. The note indicated R1 resided in room W2 and required 4 liters of continuous oxygen to keep his oxygen saturation (O2 sat) above 90%. (normal O2 sat is 98-100%). Observation conducted on 6/18/20 at 10:39 AM revealed Licensed Nurse LN1 entered room W2 wearing a facemask (surgical mask) then donned a gown and gloves. Surveyor (wearing an N95 mask/respirator) continued observation from the doorway of room W2 with the door open just enough to see into the entire room. R1 sat in a wheelchair facing the door, he wore a facemask with tubing attached to a nebulizer machine. (Nebulizers turn liquid medications into fine inhaled droplets (mist) that the person can inhale through a mask or mouthpiece) LN1 removed the nebulizer mask and explained the resident required two different nebulizer treatments 10 minutes apart so she needed to wait a few minutes to start the second treatment. LN1 rearranged the room to accommodate R1's personal electronic devices. LN 1 prepared the nebulizer with medicated solution, applied the nebulizer mask to R1 and turned on the nebulizer machine. The mask immediately began emitting a mist and R1 coughed. LN1 leaned over to within 12-18 inches of R1's face and adjusted R1's mask several times. The mist (droplets) was visible in LN1's face and around her head. LN1 did not wear eye protection. At 10:51 AM LN1 pinched the top of her surgical mask and pushed it up. LN1 did not perform hand hygiene and proceeded to handle resident supplies in the room. LN1's gown was not tied and exposed her hips and upper torso as it fell down with movement. R1 coughed several times producing sputum which he spit into tissues. LN1 took the tissues with her gloved hands. LN1 stood next to R1 and held the tissues until the coughing stopped then discarded the tissues. LN1 did not change gloves or perform hand hygiene after she discarded the sputum-soiled tissues. LN1 leaned close to R1 to talk to him and she again touched her facemask while wearing the soiled gloves. Upon completion of the treatment, LN1 removed the nebulizer mask and placed oxygen on R1. LN1 removed the soiled gloves and washed her hands as she left the room. ICS was interviewed following the above observation. ICS confirmed the nebulizer treatment was an aerosol generating procedure (AGP). When asked the rationale to require contact precautions while providing care to R1, but not special droplet precautions with appropriate PPE for aerosol generating procedures, ICS said she initially questioned the level of precautions. ICS said she thought special droplet precautions were indicated but was told it was the facility policy so she did not make changes. Signage on the door indicated special droplet precautions were required for resident room E3. The sign directed; *only essential personnel *clean hands when enter and when leave room *wear N95 or higher for aerosolizing procedures *eye protection *gown and glove at the door. The signage directed the order to doff (remove) PPE: 1. Gloves 2.gown 3.wash or gel hands 4.mask and eye cover 5. Wash or gel hands (even if gloves used). A caddy (shelf unit) hung on the outside of the door and had compartments that held gowns, masks, face shields, and gloves. Observation on 6/18/20 at 11:40 revealed licensed nurse LN2 exited room E3. LN2 removed the gown, then gloves, and finally the facemask with attached eye shield and discarded them in the room. LN2 did not remove the PPE in the order directed on the posted sign. LN2 did not perform hand hygiene after removing gown (step 3) and did not perform hand hygiene after removing the PPE (step 5). LN2 went directly from E3 to the medication cart carrying a glucometer (hand-held device used to measure the level of glucose in the blood). LN2 placed the glucometer on the medication cart then performed hand hygiene. When asked if the glucometer was used for other residents, he said yes it was but he cleans it first with Sani-Wipes (disinfectant wipes). LN2 wiped the glucometer with the Sani-Wipes and placed it back on the medication cart. LN2 but did not wipe the surface of the medication cart and did not place a barrier to separate the sanitized glucometer from the medication cart surface. In an interview on 6/18/20 at 11:42 AM LN2 said he was the charge nurse for the E Hall. When asked about a brown paper bag containing a facemask and shield labeled JH and dated 6/18/20 in the isolation supply caddy, LN2 said he did not know but maybe they were saving it to re-use it. LN2 said he did not re-use PPE supplies. Regarding donning and doffing PPE, LN2 said he followed the directions posted on each door. At 11:50 AM nursing assistants NAC 2 and NAC3 prepared to enter room E3. NAC3 removed a facemask she wore and placed it in the PPE supply caddy. The facemask was not folded properly (outside of mask folded inside) to prevent contamination, was not placed in a paper bag, and no barrier was placed to protect the isolation supply caddy from contamination by the mask. NAC3 properly donned PPE and entered room E3. The CDC website at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html included instruction regarding extended use of facemasks: Implement extended use of facemasks. Extended use of facemasks is the practice of wearing the same facemask for repeated close contact encounters with several different patients, without removing the facemask between patient encounters. *The facemask should be removed and discarded if soiled, damaged, or hard to breathe through. *HCP must take care not to touch their facemask. If they touch or adjust their facemask they must immediately perform hand hygiene. *Facemask removal and replacement be done in a careful and deliberate manner. Facemasks should be carefully folded so that the outer surface is held inward and against itself to reduce contact with the outer surface during storage. *The folded mask can be stored between uses in a clean sealable paper bag or breathable container. At 11:56 AM LN2 donned PPE to enter room E3. LN2 did not perform hand hygiene; LN2 donned the gown then the gloves and finally the facemask with attached eye shield. LN2 did not follow the posted instructions which read: PPE: put on in this order 1. Wash or gel hands (even if gloves are used) 2. Gown 3. Mask and eye cover. 4. Gloves. Upon exiting room E3 NAC3 retrieved the facemask from the PPE supply caddy and put it on. NAC3 wiped the face shield with disinfectant wipes then folded the attached mask and put it in the paper bag on the door caddy. NAC3 did not fold the mask properly to prevent contamination for re-use. NAC2 placed the facemask and shield she used in a paper bag and placed the paper bag on an open box of gloves that sat on top of the paper towel dispenser in room E3. Hand hygiene and gloves Observation conducted on 10:15 AM revealed NAC1 pushed Resident R6 from near resident room N12 on North Hall to the common (dining) area. NAC1 patted R6's shoulder and touched the wheelchair handles, wheelchair arms, and the bare skin of R6's forearms. Without performing hand hygiene, NAC1 proceeded to open cupboards in the dining room in search of a clothing protector. NAC1 opened the door on the nurse station and handled her microphone to speak to another staff. NAC1 walked half way down North Hall to the snack cart and obtained a snack for R6. NAC1 did not wash hands or use ABHR (alcohol-based hand rub) and did not offer R6 the opportunity to wash or sanitize his hands when NAC1 served R6 an individual package of chips to be eaten with fingers. NAC1 went directly from the dining area to the snack cart without performing hand hygiene, put on gloves, and continued to deliver snacks. While standing at the snack cart, NAC1 adjusted her facemask. Using both hands, NAC1 held the mask at the lower edge near her mouth and pulled the bottom of the mask down over her chin. NAC1 did not perform hand hygiene after touching her facemask. NAC1 did not perform hand hygiene prior to entering R11's room to provide a snack. R11 dropped the plastic spoon on the floor and picked it up. NAC1 obtained a clean spoon from the snack cart and re-entered R11's room. NAC1 took the soiled spoon in her hand and discarded it. NAC1 went to the sink and turned on the water. NAC1 was observed to pass her fingers into and immediately out of the stream of water for a total of 1-2 seconds. NAC1 did not use soap and did not wash her hands according to facility policy after handling the contaminated spoon. NAC1 entered room N9 without hand hygiene and then went directly into room N5. While in room [ROOM NUMBER] NAC1 moved the walker, touched her facemask, and touched the bed linen. NAC1 went from room [ROOM NUMBER] to the snack cart and put on gloves without first performing hand hygiene. NAC1 continued to deliver snacks. The findings were shared with ICS who stated staff should perform hand hygiene by washing with soap and water or using ABHR before entering and when leaving a resident room, and before handling food. ICS said staff should not touch the facemask and must immediately perform hand hygiene if the facemask is touched. ICS said she was surprised because NAC1 said all staff were educated on handwashing technique and expectations. ICS said NAC1 did not wash hands as the facility instructed. ICS provided the facility policy titled HAND HYGIENE with a review date of 11/19 and a policy titled USING GLOVES reviewed 08/19. The Hand Hygiene policy stated: All personnel working in the facility are required to wash their hands before and after resident contact, before and after performing any procedure, after sneezing or blowing nose, after using the toilet, before handling food, and when hands become visibly soiled. Alcohol Based Hand Rub (ABHR) may be used unless: 1.Potential of Actual contact with bodily fluids. 2. If hands are visibly soiled. The Procedure listed 14 steps for handwashing that included; 4.Wet hands and wrists thoroughly under running water. 6 .Apply a small amount of soap or antiseptic, lathering thoroughly. 7. Wash hand using plenty of lather and friction for at least 20 seconds. The Using Gloves policy stated the purpose: To provide guidelines for the use of gloves for resident and employee protection. 1.f. Non-sterile gloves should be used primarily to prevent the contamination of the employee's hands when providing treatment or services to the resident and when cleaning contaminated surfaces. 1.g. Wash hands after removing gloves. Gloves do not replace hand washing. During an interview with ICS, IP and DNS on 6/18/20 at 1:15 PM surveyor discussed observations and findings regarding transmission-based precautions for R1 with unknown COVID-19 status, the level of PPE protection for staff who performed aerosol generating procedures (nebulizer treatments) with R1, and general breeches in infection control related to hand hygiene and PPE use. ICS confirmed the facility utilized the Centers for Disease Control (CDC) as a reference source for infection control concerns. The CDC website at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html included a section: Preparing for COVID-19 in Nursing Homes that included the following: Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. ISC, IP, and the DNS stated all staff were trained regarding hand hygiene and PPE use and the observed infection control breeches did not meet facility expectations and were not acceptable. Regarding the COVID-19 status of R1, ISC said the facility tested all residents at admission but she was not sure if a COVID-19 test was sent out yet for R1. ISC said the facility had to wait for the lab to bring a test kit to the facility before a specimen could be collected. ISC said she did not know if a test kit was requested. IP said it took a couple of days to get the result back once the specimen was collected and sent out to the laboratory. When asked about the rationale why the facility required contact precautions and not special droplet/contact precautions to ensure eye protection during aerosolizing procedures until R1's COVID status was known, ISC said the hospital would have tested R1. Review of hospital records revealed no COVID-19 test. The DNS confirmed with the hospital that no COVID test was performed. ISC said she was confident R1's symptoms of cough and shortness of breath were not COVID related because he had a [MEDICAL CONDITION] [DIAGNOSES REDACTED]. The World Health Organization and CDC websites indicate a person may be pre-symptomatic (before symptoms show) but infectious and able to spread COVID-19 virus and in some cases persons with COVID-19 may have no symptoms. In these instances reliance on symptom screening alone may fail to detect COVID-19. After discussion, ISC, DNS, and IP confirmed that R1's COVID status was unknown and further acknowledged that R1 could potentially have COVID-19 in addition to his underlying condition of [MEDICAL CONDITION] or may have COVID-19 without showing symptoms. ICS and IP concurred that symptoms of COVID-19 may not be evident for 14 days after exposure and R1 and new admissions and re-admissions should be on special droplet/contact precautions for a minimum of 14-days after admission to the nursing home to prevent introduction and spread of COVID-19 in the nursing home. On 6/18/20 at 3:05 PM the facility (home) administrator (HA) and Director of Nursing (DNS) were verbally informed the findings related to infection control placed all residents in the facility at risk for exposure to and potential for infection with COVID-19 which constituted immediate jeopardy. The facility was provided written documentation of the immediate jeopardy via email to the nursing home administrator on 6/18/20 at 9:00 PM. On 6/19/20 at 9:30 AM, HA presented a plan to remove the immediacy. The plan included immediate placement of R1 on COVID-19 droplet precautions with communication to staff, posting of proper signage for droplet precautions and procedures for donning and doffing PPE. The facility revised the procedures for new admissions to include review and approval by the infection preventionist prior to acceptance for admission, COVID-19 testing procedures, and appropriate transmission-based precautions. The plan included inservice for all staff regarding droplet precautions and 1 on 1 inservice with employees as indicated. On 6/19/20 observations, interviews, record review to include facility policies and training documentationc onducted on site at the facility from 9:20 AM through 2:30 PM validated effective implementation of the removal plan. On 6/19/20 at 1:30 PM the facility administrator was informed the immediacy was removed.

Based on staff interview, record review, facility policy review, Incident and Accident Report review, Grievance Log review, and State Survey Agency Reportable Incidents Database review, it was determined the facility failed to ensure allegations of abuse were investigated and written allegations of abuse were not altered to minimize the severity of the allegations. This was true for 1 of 15 residents (Resident #3) reviewed for abuse. The health and safety of all residents residing in the facility were placed in immediate jeopardy when a) Resident #3 was at risk of ongoing abuse by facility staff and b) the other 56 residents residing in the facility were at risk of being subjected to abuse without detection and intervention. Findings include: The facility's Abuse Prevention Program Policy, revised 10/2016, documented all reports of resident abuse, neglect, and injuries of unknown origin, were to be investigated. All employees, facility consultants, attending physicians, family members, and visitors were to promptly report any incident or suspected incident of neglect or abuse, including injuries of unknown source, to facility management. The policy documented physical abuse included hitting, slapping, pinching, kicking, etc. The facility's Abuse Prevention Program Policy documented the individual conducting the investigation should at a minimum: *Interview the person(s) reporting the incident. *Interview any witnesses to the incident. *Interview the resident (as medically appropriate). *Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. *Interview the resident's roommate, family members, and visitors. *Interview other residents to whom the accused employee provides care or services. *Review all events leading up to the alleged incident. *Employee(s) accused of resident abuse were to be removed from the facility and could not work until the investigation was completed. This policy was not followed. Resident #3 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 4/16/19, documented Resident #3 had severe cognitive impairment and he required the assistance of one to two staff members for his ADLs, and he had an indwelling catheter. A care plan, revised 3/25/19, documented Resident #3 was at risk for falls related to impaired balance, confusion, and impulsive behaviors. The care plan interventions included encouraging Resident #3 to wear non-skid socks, keep his pathways clear and free from clutter, keep his room well lit, keep his call light within reach, and to provide him with supportive care. An Incident and Accident (I&A) report, dated 9/18/18 at 1:30 AM, documented Resident #3 had an unwitnessed fall with no injury. The I&A report documented Resident #3 was found kneeling on the floor with both hands resting on his bed. Resident #3 was not wearing his non-skid socks and said Help, help, help me up. On 4/25/19 at 4:05 PM, the Resident Care Manager (RCM) said she remembered a conversation with CNA #3 where she reported RN #1 yelled at Resident #3. The RCM said she did not remember exactly what CNA #3 told her, but she remembered talking to the DON about her conversation with CNA #3. The RCM said she and the DON spoke to Resident #3 and asked him if he felt safe in the facility. RCM said Resident #3 said yes. On 4/25/19 at 4:21 PM, the DON said CNA #3 told her RN #1 slapped Resident #3's ears and CNA #3 was concerned about Resident #3's safety in the facility. The DON said she clarified to CNA #3 the difference between the words slapping the ears and cupping the ears. The DON said she explained and demonstrated to CNA #3 the difference between cupping the ears and slapping the ears. The DON said Resident #3 was hard of hearing and it could be RN #1 was trying to get his attention because he was not wearing his hearing aid the night he fell . The DON said she interviewed RN #1, and RN #1 told her she put her hands on Resident #3's ears to get his attention. The DON said she was not sure if she kept the written report from CNA #3. On 4/25/19 at 4:46 PM, LSW #2 who was the Abuse Coordinator, said there was no investigation done into the alleged abuse because the DON clarified to CNA #3 the difference between the words slapping and cupping. LSW #2 said RN #1 did not slap Resident #3's ears, instead RN #1 cupped her hands against Resident #3' ears to get his attention. LSW #2 said there was no abuse to Resident #3, it was instead a misuse of words. On 4/25/19 at 5:28 PM, during a telephone interview, RN #1 said during her shift on 9/18/18, she heard Resident #3 calling for help and saying, help me, help me. RN #1 said she found Resident #3 kneeling on the floor with his hands resting on his bed. RN #1 said she asked CNA #3 to get the Hoyer lift (a mechanical lift) while she assessed Resident #3 for injury. RN #1 said Resident #3 was still yelling for help even though she was already in his room, and it became louder and louder. RN #1 said she tapped Resident #3's ears to let him know she was already there and trying to help him but Resident #3 kept yelling. RN #1 said she then used her feet to tickle Resident #3's feet to get his attention, but Resident #3 kept yelling for help. On 4/25/19 at 6:00 PM, CNA #3 said on 9/18/18 she heard Resident #3 yell for help and found Resident #3 kneeling on the floor next to his bed. CNA #3 said she called RN #1 for help. CNA #3 said Resident #3 kept on yelling for help even though they were already in his room trying to assist him. CNA #3 said RN #1 stood behind Resident #3 to support him and every time Resident #3 yelled for help RN #1 kicked his feet. CNA #3 said Resident #3's catheter tubing was caught between one of his legs and the floor and when RN #1 pulled him back to a sitting position Resident #3 yelled stop you are hurting me. CNA #3 said she then saw RN #1's hands about 12 inches away from Resident #3's ears and she then slapped his ears. CNA #3 said her command of the English language was not good, so she described it in her report as a clapping sound. CNA #3 said it was really loud and it mimicked the sound of clapping your hands. CNA #3 said she reported the incident to the Unit Manager the following morning and she was asked to provide a written report of the incident. CNA #3 said the DON talked with her and explained to her the difference between cupping of the ears and slapping of the ears. CNA #3 said she described what she saw and heard that night in her written report. CNA #3 then provided a copy of her written report to the surveyor. The words in the report were changed as follows: * kick was changed to tap * hit him was changed to tap his * lower back was changed to l(ower) flank * slap was changed to cupp The changes were not initialed or dated. Unedited, CNA #3's written report documented the following: * RN #1 kicked Resident #3 in the feet each time he screamed help me. * RN #1 told Resident #3 to stop screaming as they were there to help him and that he made her headache more and she did not feel well. * When Resident #3 screamed again RN #1 kicked him on his left side between the lower back. * RN #1 pulled back on Resident #3 to get him from a kneeling to a sitting position and Resident #3 said stop it you are hurting me. * Resident #3 screamed for help again and RN #1 slapped both of his ears. Resident #3 told RN #1 to stop because it was hurting him. On 4/26/19 at 9:44 AM, the Administrator, with the DON present, said when the words cupping the ears and slapping the ears were clarified with CNA #3 it should have been documented and included in the incident report. The Administrator said it was unfortunate they could not provide that document. The Administrator said he was not notified of CNA #3's report. The DON said she did not notify the Administrator of the incident because it was concluded there was no abuse to Resident #3. The DON said there was a language barrier between CNA #3 and RN #1. On 4/26/19 at 11:02 AM, during the follow-up interview with the Administrator, DON, RCM, and LSW #2, the surveyor provided a copy of CNA #3's report for review. The DON and the RCM both said this was the first time they had seen the report. LSW #2 said CNA #3's report was not in his Grievance log. LSW #2 said if CNA #3's report was submitted to him it would be in his Grievance log. The DON said when CNA #3 came to her she had a written report on a piece of paper taken from a notebook and she was unable to find it. The Administrator then read CNA #3's report and after reading the report, the surveyor asked the Administrator what he would have done if he had the report earlier. The Administrator said, without a doubt it will be reported to the State portal and an investigation initiated. The facility failed to investigate the allegation of abuse to Resident #3 and protect him further abuse, as documented in its Abuse Prevention Program Policy. Additionally, the original written allegation of abuse was altered and neither the original or altered written allegation was retained by the facility. On 4/26/19 at 1:10 PM, the Administrator was notified verbally and in writing of the Immediate Jeopardy to residents' health and safety.

Based on observation, staff interview, resident interview, and record review, it was determined the facility failed to prevent the development and worsening of pressure ulcers, and failed to provide services to promote healing, prevent infection, and prevent new ulcers from developing for 2 of 7 residents (#43 and #107) reviewed for pressure ulcers. This failure resulted in harm to Resident #107 when he developed multiple pressure ulcers which became infected. Resident #43 was also harmed when he developed multiple pressure ulcers. Findings include: 1. Resident #107 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The medical record indicated he was discharged on [DATE] to the hospital and readmitted to the facility on [DATE]. The Admission Nursing Assessment, dated 10/3/16, documented a stage 1 pressure sore on the coccyx. The pressure ulcer was described as non-blanchable skin with redness, measuring 0.03 cm L(length) x (by) 0.03 cm W(width) x 0.00 cm D (depth). Resident #107's Admission MDS assessment, dated 10/10/16, documented significant cognitive impairment, a stage 1 pressure ulcer (intact skin with non-blanchable redness of a localized area usually over a bony prominence), pressure reducing devices were in place for bed and chair, required extensive assist of two or more staff for bed mobility, transfers, and toileting and did not reject care. The Braden Scale assessment, completed on 10/3/16 placed Resident #107 at risk for pressure ulcers. A Care Plan for wound to right heel, dated 10/4/16, documented the wound would resolve without complication. Interventions directed staff to inform MD of worsening and signs and symptoms of infection. A care plan, dated 10/18/16, documented the Resident was not consistently able to manage pressure relief. The care plan goal, dated 10/18/16 and revised on 1/19/17, and 4/7/17, documented measures will be in place to ensure his skin remains intact and free of breakdown through the review period. Interventions included an air mattress to bed, and directed staff to check inflation every shift and as needed, observe heels daily for redness, purple discoloration, blistering, and bogginess when providing cares, changing clothes, and assisting to bed for naps or the night, complete skin assessments weekly and notify MD of any new areas of concern, observe skin for signs of infection and breakdown, report any areas of open skin, document location, size, treatment of [REDACTED]. An unscheduled MDS assessment, dated 11/21/16, documented Resident #107 had an unstageable wound with slough and/or eschar, no measurements were documented. The location was not documented. Nurse progress notes, dated 1/3/17, documented Resident #107 was seen at the wound clinic that day. A hospital History and Physical, dated 1/3/17, documented Resident #107 was transferred from the wound clinic to the emergency room for significantly worsening bilateral heel pressure ulcers, in the setting of uncontrolled diabetes. The assessment documented the right foot had a very large right heel blister which appeared ruptured. The left foot also had a very large blister which appeared intact. The redness extended across the top of the foot and up onto the middle aspect of the shin. X-ray of the right foot showed diffuse forefoot and midfoot soft swelling suggestive of [MEDICAL CONDITION] or [MEDICAL CONDITION]. An X-ray of the left foot showed similar findings. A hospital Discharge Summary, dated 1/6/17, documented a debridement of the heel ulcers in the operating room was completed on 1/4/17. Resident #107 received antibiotic therapy for [MEDICAL CONDITION]. The facility's Admission Nursing Assessment, dated 1/6/17, documented the wound to the right heel measured 4.0 cm length x 6.2 cm width x 0.01 cm depth and the wound to the left heel measured 5.2 cm length x 3.0 cm width x 0.1 cm depth. The assessment documented the wounds as other-debridement. The note documented bilateral heels with superficial debridement, skin surrounding macerated soft edges, no drainage noted, applied new dressings per orders. A Care Plan, dated 1/9/17, documented Resident #107 had pressure ulcers to bilateral heels and shearing, pressure to coccyx, gluteal folds r/t decreased sensation, fragile skin, immobility, poor circulation, and incontinence. The goal, dated 1/9/17 and revised on 4/7/17, was for the wounds to show signs of healing over next review. Interventions included staff to assess and document location, size, depth, undermining, color, odor, and presence of necrotic tissue, assess treatment plans for further decline, describe exudate or wound drainage, alert MD for signs of infection: redness, swelling, drainage, warmth at site, or elevated temperature, culture drainage as MD orders, notify of results, float heels while in bed wheelchair cushion to assist off-loading. Each intervention was dated 1/9/17. The care plan did not direct staff to use off-loading heel sage boots for the resident. The quarterly MDS assessment, dated 1/10/17, documented 2 unstageable pressure ulcers not present on prior assessment. The MDS provided measurement of the largest ulcer, which measured 7.0 cm in length, 5.0 cm wide, and 0.5 cm deep. physician's orders [REDACTED].#107 to wear sage boots at all times for off-loading due to bilateral heel wounds. Resident #107's Weekly Skin/Wound Progress Note (WS,) Wound Care Note (WCN,) and Wound Assessment (WA,) documented pressure ulcers to the right heel, gluteal fold and left heel as follows: -Wound #1-Right Heel: *1/12/17-WS-not documented, *1/19/17-WS-pink with no eschar, no measurements, *1/19/17- WCN-4.0 cm x 5.9 cm x 0.05, wound bed was 76-100% eschar, unstageable, resident is inactive at the skilled nursing facility and was in a wheelchair most of the time and noticed that both of the heels were resting on foot pedals with sage boots on, *1/26/17-WS-pink, very dry and flaky, no measurements, *2/2/17-WS-yellow drainage with scant amount of bleeding, heel black with macerated edges, spongy, no measurements, *2/9/17-WS-draining a small amount of yellow discharge, resident complained of pain to the right heel during dressing change, no measurements, *2/10/17-WCN-3.6 cm x 5.3 x 0.4 cm, wound bed 76-100% eschar, unstageable, macerated callous and increased light green drainage, culture completed, resident's wife said the resident is not compliant with off-loading the right heel and makes successful attempts to remove the sage boots, physical therapy to evaluate wheelchair for positioning to maximize off-loading of heels. A wheelchair evaluation was completed on 3/28/17, *2/17/17-WCN-3.6 cm x 5.9 cm x 0.3 cm, culture results showed multiple bacteria, dry, black adherent eschar over the calcaneal tuberosity (bone near the heel.) *2/21/17-WS-slightly larger than a silver dollar, gray in center, pink around the center with yellow/white along the edges, a small amount of drainage noted, no odor or bleeding, *2/28/17-WS-slightly larger than a silver dollar with yellow and spongy pink tissue surrounding, old dressing shows small amount of yellow discharge, no measurements, *3/3/17-WCN-3.0 cm x 3.0 cm x 0.1 cm, a large amount of serosanguineous, (yellowish fluid with small amounts of blood,) strong odor, removed devitalized tissue, biofilm, and slough, *3/7/17-WS-wound bed yellow and spongy with pink skin surrounding, no eschar, *3/7/17-WA-3.0 cm x 2.0 cm x 0.01 cm, wound bed pink with yellow, spongy tissue, small amount of drainage, no odor, no tunneling or undermining, surrounding skin normal color for resident, wound edges irregular and smooth, improved since last dressing change, *3/14/17-WS-wound bed yellow/pink, firm, *3/14/17-WA-3.0 cm x 2.5 cm x 0.0cm, wound bed yellow and firm with smooth pink tissue surrounding, no odor, no tunneling or undermining, small amount of yellow drainage, *3/17/17-WCN-2.7 cm x 2.2 cm x 0.1 cm, debrided devitalized tissue, biofilm, and slough, *3/21/17-WS-slightly yellow with pink, granulated wound bed, *3/28/17-WS-dressing clean, dry and intact, no measurements, *3/30/17-WCN-resident was in a new wheelchair with right padding along pressure points, 2.3 cm x 1.4 cm x 0.1 cm, removed devitalized tissue, biofilm, and slough, unstageable, *4/2/17-WA-2.0 cm x 1.5 cm x 0.1 cm, minimal yellow drainage with a foul smell, resident complained of some pain, surrounding skin is pink and improving, *4/4/17-WS-dressing changed and dry and intact, *4/9/17-WA-stage 2 pressure ulcer, 2.0 cm x 1.5 cm x 0.1 cm, wound appears to be healing, some yellow drainage with a foul smell, resident complained of some pain, surrounding skin is pink. *4/11/17-WS- dressing changed and dry and intact, *4/11/17-WCN-2.0 cm x 0.9 x cm x 0.1 cm, stage 3 pressure injury, *4/17/17-WA-stage 2 pressure ulcer, 4.0 cm x 1.5 cm x 0.2 cm, purulent scant drainage with moderate odor, pink/beefy surroundings, *4/18/17-WS- dressing changed and dry and intact, *4/20/17-vascular stage 2 wound, 4.0 cm x 1.4 cm x 0.2 cm, small amount of yellow drainage, pink/beefy surroundings with scant bleeding. -Wound #2, #4, & #5-Gluteal Fold: *1/12/17-WS-reddish/purple to bilateral buttocks, the skin to coccyx was blanchable, raw/pink skin, *1/19/17-WS-blanchable to the coccyx, *1/26/17-WS-blanchable to the coccyx, *2/9/17-WS-blanchable to the coccyx, excoriation to bilateral buttocks, *2/21/17-WS-blanchable to the coccyx, excoriation to bilateral buttocks improving, *2/28/17-WS-blanchable to the coccyx, *3/7/17-WS-blanchable to the coccyx, *3/14/17-WS-blanchable to the coccyx, excoriation to bilateral buttocks continued, no open areas, *3/21/17-WS-blanchable to the coccyx, excoriation to buttocks almost resolved, open area to right gluteal fold, bleeding a small amount, no measurements, *3/27/17-WA-shearing impairment to the right gluteal fold, 3.8 cm x 4.0 cm x 0.1 cm, superficial shearing with rough edges with greenish, yellow, color, pink wound bed with surrounding wound red, very tender to the touch. *4/2/17-WA-right gluteal fold shearing wound, 4.0 cm x 3.8 cm x 0.1 cm, pink with yellow drainage, thin line of black skin. *4/4/17-WS-blanchable to the coccyx, excoriation to the buttocks improving, gluteal fold showed no drainage or bleeding, *4/9/17-WA- shearing wound stage 2, 4.0 cm x 6.0 cm x 0.1 cm. *4/11/17-WS-excoriation continues to buttocks, blanchable to the coccyx, gluteal fold grayish color, no bleeding or drainage, *4/11/17-WCN-wound #4-a new unstageable wound to the left ischial, 7.0 cm x 4.8 cm x 0.05 cm, obscured full-thickness, wound #5-a new stage 2 pressure sacral ulcer, 2.3 cm x 0.4 cm x 0.05 cm, with eschar, a new patch of dull gray skin (pressure necrosis) under left buttock skin fold, *4/17/17-WA-right gluteal fold shearing wound, 5.5 cm x 5.0 cm x 0.2 cm, unstageable, *4/18/17-WS-excoriate site to coccyx with no open area, brownish/black spongy sore to left gluteal fold with yellow/pink surrounding skin, scant amount of bleeding with a foul odor, *4/20/17-WA-left gluteal fold vascular unstageable wound, 6.0 cm x 5.2 cm x 0.7 cm, thick gray eschar, very foul odor, moderate yellow drainage with scant bleeding, wound bed tunneling 2 cm toward 1 o'clock position, surrounding skin reddened, wound condition deteriorating since last treatment. -Wound #3-Left Heel: *1/12/17-WS-heel raw/pink, *1/19/17-WS-pink, no eschar, *1/19/17-WCN-unstageable pressure injury with obscured full-thickness skin and tissue loss, 1 cm x 0.9 cm x 0.05 cm, wound bed is 76-100% [MEDICATION NAME], *1/26/17-WS-pink, no measurements, *2/2/17-WS-pink and intact, no measurements, *2/9/17-WS-pink and intact, no measurements, *2/10/17-WCN-resolved. -Wound #6-Left Lateral Abdomen: *3/14/17-WS-not documented, *3/17/17-WCN-stage 2 pressure ulcer to the left lateral abdomen, 2.1 cm x 2.0 cm x 0.05 cm, small amount of sero-sanguineous drainage, Resident #107 was in a new larger wheelchair, order to place a pillow under arm to alleviate pressure and for physical therapy to evaluate, *3/21/17-WS-shearing site to left abdomen is improving, the wound bed is pink/yellow, *3/28/17-WS-shearing to left side continues to improve with treatment, *3/30/17-WCN-1 cm x 0.9 cm x 0.05 cm, small amount of sanguineous drainage, no odor, wound bed 76-100% slough, *4/4/17-WS-scabbed site to left side abdomen improving, *4/11/17-WS-scabbed site to left side abdomen improving, *4/18/17-WS- scabbed site to left side abdomen. A progress note dated 4/22/17, documented Resident #107 was transferred to the hospital via ambulance and admitted to the hospital with [REDACTED]. On 1/26/18 at 7:45 AM, RN #2 (Senior RN) stated she would expect family and MD to be notified immediately when changes in wounds were observed and for notification be documented in the progress notes under nursing. RN #2 said that with any change of condition, the MD would be notified and staff would follow direction from the MD. On 1/26/18 at 8:15 and 10:40 AM, the DON stated she or RN #2 were to be notified regarding wounds. The wounds should show up on weekly skin checks and hopefully would show up in the clinical notes, or they would call you or show the DON. The DON stated the MD rounded every 60 days on the residents in the facility and said the MD seldom looked at the wounds. The DON stated the MD was responsible for the management of all care and the wound clinic MD would make recommendations. The DON stated the interventions were put in place, but could not force the resident to keep the sage boots on. The DON stated the resident was repositioned and turned, if we could, even on an air bed. She said there were only a few notes which documented the resident refused or resisted cares. The DON said there was inconsistent monitoring of the wounds and there was inconsistency regarding staging, sizing and characterizing the wounds. She said she was not sure why there was a delay regarding the wheelchair evaluation. The DON said she was not aware Resident #107 had a pressure to the left heel. The DON stated Resident #107 did not come back to the facility. I think he passed away. He was a very sick man. 2. Resident # 43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Nursing Assessment, dated 12/13/17, documented Resident #43 had scars to the right leg and foot, and extremely dry skin to feet and toes. The hospital Discharge Report, dated 12/13/17, documented Resident #43 had excoriation to the buttocks and an open area to the left posterior hip. The baseline care plan, dated 12/13/17, documented preventative care under the skin integrity. A Care Plan, dated 12/14/17 and revised on 1/11/18, documented the Resident was not consistently able to manage pressure relief. The care plan goal, dated 12/14/17 and revised 12/27/17, documented measures will be in place to ensure his skin remains intact and free of breakdown through the review period. Interventions included sage boots to bilateral feet as resident will allow, if Resident #43 refuses, encourage resident feet on heel lift, initiated on 12/22/17 and revised on 12/27/17 and an air mattress initiated on 12/14/17 and revised on 12/22/17. A Care Plan, dated 12/22/17 and revised on 1/11/17, documented shearing to coccyx and vascular wounds to right and left heel. The care plan goal was for Resident #43 to remain comfortable during anticipated declines. Interventions directed staff to turn and reposition every 2 hours and as needed as he will allow. Physician Orders, dated 12/13/17, did not include direction to staff for wound care. The Admission MDS, dated [DATE], Resident #43 had minimal impairment, required extensive assist for bedmobility, dressing, and personal hygiene. The MDS documented Resident #43 had one stage 2 pressure ulcer. A Treatment Administration Record, dated 1/12/18 directed staff to check proper inflation of air mattress every shift. The task was signed each shift from 12/30/17 to 1/12/18. The facility's Weekly Skin and Wound Assessments documented Resident #43 developed 3 wounds. Wound #1 Coccyx: 12/20/17 Pressure/SDTI -a deep purple/red area to the entire coccyx area measured and measured 6.0 x 6.0 cm 1/11/18 Shearing/Stage two- 1.3 x 0.1 x 0.1 cm slight purulent slough. 1/14/18 Vascular- 2.2 x 1.0 x 0.0 cm wound bed yellow/white slough 1/16/18 Vascular- 2.0 x 1.1 x 0.01 cm white center 1/23/18 Vascular-2.0 x 1.1 x 0.01 cm Wound #2 Right heel 1/11/18 Vascular/unstageable 3.0 x 2.0 x .00 cm eschar area black in color. 1/14/18 Vascular/unstageable 3.5 x 2.0 x 0.0 cm Wound black 1/16/18 Vascular/unstageable 3.8 x 3.8 x 0.0 cm dark area with soft black tissue 1/23/18 Vascular/unstageable 2.8 x 2.8 x 0.0 cm dark area surrounding heel with thick hard center Wound #3 Left heel 1/11/18 Vascular/unstageable 3.0 x 3.0 x 0.0 cm eschar area black in color. 1/14/18 Vascular/unstageable 4.0 x 3.0 x 0.0 cm wound black 1/16/18 Vascular/unstageable 1.8 x 1.8 x 0.0 cm dark area with hard black tissue 1/23/18 Vascular/unstageable 3.8 x 3.8 x 0.0 cm dark area surrounding heel with thick hard center. A nursing note, dated 1/11/18, documented attempt to contact family regarding Resident #43's declining health. On 1/25/18 at 9:00 AM, the DON stated, it is hard to meet the care plan goal when the resident came in with a wound. When asked about the changes in the types of wounds, i.e. vascular, pressure, SDTI, shearing, etc., the DON stated the wrong terminology was used. The DON stated the nurses do assessments, treatment, and documentation of the wounds but they do not have certification or training in wound care. When asked where the direction to nursing the airbed settings are checked was, the DON stated, We push down on it, if you feel the frame, or if they are on it, if it is too tight, they are going to roll out. LPN #3 stated to determine the proper airbed setting she put her hand between the bedframe and mattress to see if you feel the resident. The manufacturer's directions for use guided user: to check to see if suitable pressure is selected by sliding one hand between the air mattress and the air/foam base under the resident's buttock. User should be able to feel the space between their hand and the resident's buttocks with the acceptable range being 1-1.5 inches. On 1/26/18 at 8:05 AM, LN #3 stated Resident #43 had pedal pulses and his feet were warm to the touch. No documentation was found in the medical record to indicate Resident #43 had vascular impairment. On 1/26/18 at 10:40AM, RN #2 stated she completed wound rounds and compared weekly wound measurements provided by the nurses. RN #2 stated she did not assess the wounds, complete dressing changes or measurements. The medical record did not reflect referal to the wound clinic. The DON stated Resident #43 had bad skin, we tried turning him, he just wanted to be left alone.

Based on observation, staff interview, and record review, it was determined the facility failed to ensure residents who were incontinent of urine received the care and services to improve their level of continence. This was true for 1 of 9 (#2) sampled residents. Resident #2 was harmed when he was found unresponsive and was hospitalized for [REDACTED]. Findings included: 1. Resident #2 was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. The 1/3/14 Bowel and Bladder Incontinence care plan, related to impaired mobility and [MEDICAL CONDITION], documented a goal, initiated 1/27/14, that the resident's risk for [MEDICAL CONDITION] would be minimized/prevented via prompt recognition and treatment of [REDACTED]. Interventions included: *BLADDER RETRAINING PROGRAM: Offer, assist me to toilet upon my request, upon my rising and prior to bed, prior to and/or after my meals, Q (every) 4 hours at night and PRN upon my request, initiated 7/31/14; *Establish voiding patterns, initiated 7/31/14; *INCONTINENT: Check (often) and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes, initiated 1/27/14; *Monitor/document for s/sx (signs and symptoms) UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp(erature), Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns, initiated 1/27/14; and, *Monitor/document/report PRN any possible causes of incontinence; bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, Stroke, medication side effects, initiated 2/17/14. NOTE: Resident #2's medical record did not include a bladder assessment prior to the 1/3/14 care plan. The 10/29/14 Quarterly MDS Assessment documented the resident was moderately cognitively impaired with a BIMS Score of 9, required extensive assistance of 1 person for toilet use, was frequently incontinent, and on a toileting program. A 12/11/14 Bowel and Bladder Screener for scheduled toileting documented the resident voided apppropriately without incontinence, and was immobile or required the assistance of two staff members for toileting CNA charting for December 2014 Bladder Activity documented the resident was toileted at the following times: 12/1 - 2:24 a.m., 10:26 a.m., and 2:49 p.m. 12/2 - 1:38 a.m., 9:14 a.m., and 6:09 p.m. 12/3 - 1:59 p.m. 12/4 - 1:51 p.m. 12/5 - 9:34 a.m. 12/6 - 11:47 a.m. 12/7 - 1:59 p.m. 12/8 - 1:59 p.m. 12/9 - 9:47 a.m., and 3:05 p.m. 12/10 - 7:26 a.m., and 9:19 p.m. 12/11 - 3:18 a.m., 8:44 a.m., and 2:33 p.m. 12/12 - 1:35 a.m., 10:37 a.m., and 9:51 p.m. 12/13 - 3:00 a.m., 10:42 a.m., and 9:00 p.m. 12/14 - 5:42 a.m., 1:59 p.m., and 2:57 p.m. 12/15 - 3:15 a.m., 10:14 a.m., and 2:58 p.m. 12/16 - 10:46 a.m., 3:36 p.m., and 11:02 p.m. 12/17 - 3:15 a.m., 10:37 a.m., and 9:05 p.m. 12/18 - 2:43 a.m. 9:52 a.m. and 4:05 p.m. 12/19 - 1:48 a.m., 9:28 a.m. and 3:08 p.m. 12/20 - 3:37 a.m., 11:53 a.m., and 8:44 p.m. 12/21 - 2:40 a.m., 10:42 a.m., and 2:52 p.m. 12/22 - 12:07 a.m., 9:37 a.m., and 2:46 p.m. 12/23 - 3:34 a.m., 12:54 p.m., and 9:59 p.m. 12/24 - 12:26 a.m., 9:20 a.m., and 9:59 p.m. 12/25 - 4:31 a.m., 9:48 a.m., and 2:53 p.m. 12/26 - 12:06 a.m., 9:54 a.m., and 9:04 p.m. 12/27 - 3:39 a.m., 9:23 a.m., and 2:28 p.m. 12/28 - 5:56 a.m., 10:32 a.m., and 2:46 p.m. 12/29 - 5:59 a.m., 10:59 a.m., and 2:30 p.m. 12/20 - 5:33 a.m., 9:40 a.m., and 9:56 p.m. 12:31 - 5:45 a.m. and 10:10 a.m. NOTE: Record review revealed the resident was admitted to a local hospital from 12/2/14 to 12/10/14, yet the facility continued to document that staff toileted the resident during that period. CNA charting for January 2015 Bladder Activity documented the resident was toileted at the following times: 1/1 - 1:01 a.m., 9:49 a.m., and 6:06 p.m. 1/2 - 5:38 a.m., 11:45 a.m., and 9:31 p.m. 1/3 - 1:06 a.m., 9:47 a.m., and 3:27 p.m. 1/4 - 2:54 a.m., 10:45 a.m., and 3:05 p.m. 1/5 - 5:54 a.m., 1:59 p.m., and 2:14 p.m. 1/6 - 3:41 a.m., 1:59 p.m., and 3:51 p.m. 1/7 - 2:04 a.m., 11:48 a.m., and 9:59 p.m. 1/8 - 5:55 a.m., 10:10 a.m., and 9:59 p.m. 1/9 - 12:12 a.m., 9:14 a.m., and 9:59 p.m. 1/10 - 5:59 a.m., 9:26 a.m., and 9:59 p.m. 1/11 - 4:34 a.m., 10:44 a.m., and 2:49 p.m. 1/12 - 2:51 a.m., 10:20 a.m., and 9:59 p.m. 1/13 - 2:17 a.m., 11:07 a.m., and 3:17 p.m. 1/14 - 4:50 a.m., 10:29 a.m., and 9:59 p.m. 1/15 - 3:26 a.m., 11:07 a.m., and 2:46 p.m. 1/16 - 5:32 a.m., 1:59 p.m., and 9:59 p.m. NOTE: Record review revealed the resident was admitted to a local hospital from 1/14/15 to 1/16/15, yet the facility continued to document that staff toileted the resident during that period. A Progress Note (PN), dated 1/14/15 at 6:15 PM, documented, Resident nonresponsive skin pale very warm to touch, temporal T-100.2, BP (Blood Pressure) 110/58, AP (Apical Pulse) 102, R (Respirations) 36, shallow and labored, diminished sounds bilateral upper lobes, absent bilateral lower lobes. Sp 02 (saturation of oxygen) 88% @ (at) 2 lpm (liters per minute) increased to 3 lpm, no change in saturation. MD notified, sent to ER (emergency room ) as in 'POST' (Physician order [REDACTED]. Message left with family to call facility. Non-emergent EMS notified and transfer to (a local hospital) ER for further evaluation @ 1830 (6:30 PM). NOTE: No progress note was found in the facility medical record which indicated the resident had been monitored for s/sx of a urinary tract infection as directed in the bladder incontinence care plan initiated on 1/27/14. A PN, dated 1/14/15 at 11:25 PM, documented, Resident admitted to the Med/Sug. (sic) floor for the Dx. (Diagnosis) of UTI and for IV (Intravenous) ABO (antibiotic) therapy. The History and Physical, from a local hospital, dated 1/15/15, documented, In the Emergency Department, the patient initially was unresponsive . He has been brought to this facility multiple times for altered mental status and many times it is related to urinary tract infection. As a result, the patient in the Emergency Department was started on [MEDICATION NAME] for urinary tract infection. The Discharge Summary from a local hospital, dated 1/16/15, documented the following primary discharge Diagnoses: [REDACTED]. Altered mental status due to urinary tract infection (complicated); and, 2. Urinary tract infection due to Proteus mirabilis in the setting of benign prostatic hypertrophy, but no overt [MEDICAL CONDITION] here. The Discharge Summary further documented, In brief, the patient came in with a decreased level of consciousness and altered mental status compared to his baseline. He was evaluated in the emergency room , had frank pyuria (presence of white blood cells or pus in the urine) and was placed on broad spectrum antibiotics . His urine culture the following day showed swarming proteus and so I changed to [MEDICATION NAME] . to [MEDICATION NAME]. The patient showed significant improvement in the past 24 hours with mental status returning to baseline. No fevers . The patient will be discharged with seven additional days of [MEDICATION NAME] 500 MG by mouth two times a day. Record review revealed the first Bowel and Bladder assessment was dated 2/17/15 and documented the resident had gradual onset of bladder incontinence, which was stable with a 1-2 year history of duration. The voiding pattern section was left blank for the question of how frequently the resident toileted on average each day. For the symptoms of overflow incontinence, the assessment documented, unknown. For the question, Do you feel that you completely empty your bladder when you pass urine, the assessment documented the following: *Occasional urge incontinence and could hold urine for 5 minutes after feeling the first urge; *Occasionally was aware of the urge to void, of urine being passed, and trouble starting to pass urine; *Not aware of being wet; *Voiding record had not been initiated; and, *Type of bladder incontinence was listed as Functional (Functional incontinence is defined as when a person does not recognize the need to void or does not recognize where the toilet is located). *Contributing factors included weight, cognition, medications, and mobility. On 6/29/15 at 10:05 AM, Resident #2 was observed in bed sleeping when two staff members came in and assisted the resident to move up in bed. Staff were not observed to check the resident's brief. The resident was observed sleeping in bed at 11:00 AM and 1:30 PM. At 2:30 PM, LN #2 was observed as she came into the room, checked the resident's brief, which was dry, and transferred the resident to his wheelchair with the assistance of another staff member. On 6/30/15 at 2:00 PM, Resident #2 stated he remembered a time when he asked for help to the toilet and staff did not get back to him for 1-1/2 hours. He stated, It only happened one time but it made me feel like an idiot. On 7/1/15 at 2:25 PM, LN #2 was asked to explain the Bladder Retraining Program intervention. She stated the resident should be offered toileting before and after meals, upon rising and before bedtime. LN #2 stated, We don't have a check and change program. When asked for the resident's established voiding program, as care planned 7/31/14, LN #2 stated, I do not see an assessment. When asked about the INCONTINENT intervention and what check often meant, as care planned 1/27/14, LN #2 stated check often meant at least every two hours. LN #2 was then asked how often incontinence care was provided and where it was documented. She stated, At least every 2 hours and PRN, I'll look at our Bladder Policy. When asked to explain the resident's UTI history, LN #2 stated the resident did not have a strong history of UTI's and that 1/14/15 was his first UTI and his second UTI was 6/6/15. She stated the resident had overflow incontinence due to [MEDICAL CONDITION] (Benign Prostate Hypertrophy) and functional incontinence. LN #2 provided a copy of the Policy and Procedure (P&P) for Perineal Care, which documented perineal care should be given each morning and evening and more frequently if needed. At this time, the DON joined the conversation for review of the policy, which documented, All residents wearing continent briefs would be checked for need of changing. When asked how often a resident would be checked, the DON stated, As often as they need it, I don't see the problem. On 7/2/15 at 7:35 AM, LN #2 stated, Bladder Assessments are like Safety Assessments. The outcome is what is important, not to have an unavoidable decline in bladder incontinence. How we get there is facility based, so I may not always have a Bladder Assessment unless he's had a decline in bladder continentcy. When asked how the facility measured the decline in continence, LN #2 stated, By the MDS, then we do a bladder assessment if they had a decline in continence. When asked how the facility assessed bladder declines for a resident with [MEDICAL CONDITIONS] or retention, LN #2 stated, We don't measure, we keep track of urine output. We chart daily on urinary output in PCC (Point Click Care), there is nothing that says you have to measure. When asked how the facility evaluated declines in bladder continency, LN #2 stated, Every week I pull a significant change report that shows any declines in daily living or continency. This report goes to the Restorative Nurse and she interprets the report and completes assessments as needed. On 7/2/15 at 10:00 AM, LN #2 stated, At one time, we decided to do a Bowel and Bladder Assessment on everybody in the building after noticing on the Quality Assurance that we were getting close to threshold for bladder continency. She provided a copy of the 2/17/15 Bowel and Bladder Assessment for Resident #2 and stated, I don't know there was a Bladder Assessment done before that time. LN #2 stated she found a 12/11/14 Bowel and Bladder Screener that included a category, Candidate for Schedule Toileting, (timed voiding), however this section did not include a documented outcome. When asked what was done for the resident after the 12/11/14 assessment, LN #2 stated, I don't have a nurse's note pertaining to the bladder screener done on 12/11/14. When asked for the policy and procedure for the Bladder Training Program, LN #2 stated, I don't know if there is a P&P. When asked about the Bladder Retraining Program as care planned on 7/31/14, LN #2 stated, There is retraining and something to help them maintain continency without further declines. A cognitive person can do a Retraining Program, (Resident #2) cannot. When shown the 7/31/14 care plan intervention, LN #2 stated, It shouldn't say bladder retraining, it should say prompted voiding. I wrote that wrong. On 7/2/15 at 10:40 AM, LN #2 provided a copy of the Bladder Assessment and Retraining Policy and Procedure, which documented, Bowel and Bladder screening will be completed on each resident within seven days of admission, quarterly and on any resident identified as having a change in continence status which would benefit from further assessment . results of this assessment shall be included in the care plan as appropriate. Additionally, the policy documented, Once the decision is made for bladder retraining the Restorative Nurse will implement the retraining program for 30 days. Each week the Restorative Nurse will document progress, or lack thereof in the progress notes. If the resident is unable to show progress in a 30 day period then discontinue the program. The Restorative Nurse will make recommendations for staff to follow such as routine toileting program, to take to bathroom upon rising, before meals, after meals and at bedtime and PRN. Resident #2 was harmed when the facility: *Failed to recognize the resident had a history of [REDACTED]. and Physical; *Failed to follow its policy and procedure to complete quarterly assessments or complete a bladder assessment when the resident experienced a change in continence status, such as after being hospitalized for [REDACTED].>*Annual and Quarterly MDS assessments documented the resident was on a toileting program, however the facility failed to follow its policy and procedure for Bladder Retraining, and did not document the resident's progress or lack thereof. In addition, LN#2 stated the resident should have been on a prompted voiding schedule due to his cognitive status; *Failed to establish a voiding pattern as care planned; *Failed to check often for incontinence as care planned and failed to check the resident for toileting needs every 2 hours or PRN; *Failed to monitor for s/sx of UTI's as care planned. The resident presented to a local hospital emergency room with frank pyuria, was hospitalized , and required IV antibiotic therapy after he was found unresponsive in bed with an elevated temperature and respiration rate.

Based on record review, staff interview, and observation it was determined the facility failed to ensure that residents who entered the facility without a pressure ulcer did not develop pressure ulcers. This was true for 3 of 3 sampled residents (#'s 1, 6, and 7) reviewed for pressure ulcers, and resulted in harm for two of the three residents. *Resident #1 was harmed when he developed multiple unstageable pressure ulcers on his right foot and ankle after compression wrappings were left on four days longer than was ordered; *Resident #6 developed blister to his right heel; and *Resident #7 experienced the potential for harm when he developed a stage II pressure sore to his finger two days after the facility implemented the use of a new hand splint. Findings include: 1. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #1's annual MDS, dated [DATE], documented in part: -Was moderately cognitively impaired; -Required extensive assistance with 2 or more staff for bed mobility, transfers, and toilet use; -Did not reject cares; -Was at risk for developing pressure ulcers; and -Had no pressure ulcers. The Care Plan for Resident #1, dated 1/9/14, documented, "The resident has potential for impairment to skin integrity r/t (related to) [MEDICAL CONDITION], fragile skin, hx (history) of rash, fungal rash to toes, wears ted hose, hx of shearing to buttocks, and wound to feet/toes with a history of these wounds." The goals initiated on 1/9/14 and revised on 3/5/14 documented in part: - "Keep skin clean and dry. Use lotion on dry skin (1/9/14); -(Resident) likes to sit in his chair and elevate his legs to help reduce swelling during the day (1/9/14); -The resident needs assistance to apply heel lift boots (1/9/14); -Use Heel lift cushion when in bed as needed to provide pressure reducing relief to bilateral heels (1/9/14); -Weekly treatment documented to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations (1/9/14); -The resident needs air bed to protect the skin while IN BED (3/10/14); and -Avoid letting right heel rest on foot peddle (sic) (3/5/14)." The resident's Medication Review Report (Physician Recapitulation orders) dated 2/3/14, documented in part: -"Blue Heel Float Boots When in Bed. every shift...; -Ted Hose on in AM, Off in PM every day and evening shift...; and -Weekly Skin Assessments every day shift every Wed (sic)..." The resident's Physician Rounding Orders, dated 2/3/13, documented in part: "-Order Unna boots to be applied to b/l (bilateral) lower extremities(LE) and #2, 4 inch and #2, 6 inch Ace bandage to be applied to b/l LE and changed weekly...; and -(Resident's physician) will apply. Until arrival of unna boot and aces apply skin repair cream [MEDICATION NAME] and Kerlix bandage to [MEDICAL CONDITION] lesion of (left) leg. Discontinue once supplies arrive." Note: An Unna boot is a compression dressing for varicose veins or ulcers consisting of a paste made of zinc oxide, gelatin, [MEDICATION NAME], and water that is applied to the lower leg, covered with a bandage, and then applied to the outside of the bandage. The resident's Physician Notes documented in part, the following: -2/11/14: "Patient was seen today for treatment of [REDACTED]. Patient relates he has had this problem for quite some time... There's generalized [DIAGNOSES REDACTED] and flaking noted to the digits and plantar surfaces of bilateral feet... Ordered Unna boot dressing and Ace to be applied to bilateral legs upon arrival... - 2/18/14: [MEDICAL CONDITION] still noted bilateral legs however greatly improved. [MEDICAL CONDITION] is +4 bilaterally. Pedal pulses are still not palpable bilateral (sic)... Two layer compression dressing was applied to the right leg. Orders were written for this dressing to be changed every four days... The resident's Physican Orders, dated 2/18/14, documented, Unna-Flex Elastic Unna Boot to right lower leg to be changed every 4th day. The resident's Physician Notes documented in part, the following: -2/24/14: [MEDICAL CONDITION] to bilateral extremities is greatly improved. [MEDICAL CONDITION] two (sic) legs almost completely resolved. There is still significant [MEDICAL CONDITION] in bilateral feet but improved. [MEDICAL CONDITION] is currently +2-3 bilaterally. [DIAGNOSES REDACTED] is greatly improved to left leg overall, superficial wound had some crust noted to it but no deep tissue involvement... Applied Unnaboot dressing to left leg. Two layer compressive dressing was applied to the right leg, to be changed every four days. Will reevaluate in one week." The resident's interdisciplinary progress notes (IDPN) documented in part: -2/24/14: "(Resident's Physician) was in to see rsdt (resident) today, rewrapped both legs with UNNA boots. No new orders; -2/26/14: Late entry, checked rsdt circulation in left foot, cap refill was >3 sec, was able to place 1 finger under wrap to check for tightness, he had no c/o (complaints of) pain; and -2/26/14: Unna-Flex Elastic Unna Boot Miscellaneous Apply to Right Lower Leg topically every evening shift every 4 day(s) related to RASH AND OTHER NONSPECIFIC SKIN ERUPTIONS; [MEDICAL CONDITION]." Note: The writer on 2/26/14 did not specify what time of the late entry. The resident's Complex Alert Documentation Report (CNA documentation) was reviewed and the behaviors: "Resist/Rejects Care" documented Day, Evening and Night shift as "NA" from 1/23/14 to 3/11/14. Note: The documentation does not indicate that the patient had behaviors resisting or rejected care for the time leading up to the pressure ulcer development. Resident #1's Medication Administration Record [REDACTED] "-Unna-Flex Elastic Unna Boot Miscellaneous (Wound Dressings) Apply to Right Lower Leg topically every evening shift every 4 day(s) related to RASH AND OTHER NONSPECIFIC SKIN ERUPTION; [MEDICAL CONDITION]." Note: The wound dressing was scheduled to be changed 3/2/14, however "other/see progress note" is coded. A physician note, dated 3/4/14, documented in part, "...Compressive dressings were noted to be intact. It was noted that the dressing to the right leg was not changed from previous visit which was eight days ago and dressing appears to be tight. Upon removal of dressing to right foot several [MEDICAL CONDITION] were noted...There was a cyanotic appearance to the foot upon removal of dressing which improved slightly over time. There was a purplish black lesion to the right fifth metatarsal head and base on the lateral aspect. The wounds are not opened and are not draining. Wound on the fifth metatarsal head measured 5.0 x 3.0 cm and the lesion to the metatarsal base measured 2.0 x 1.6 cm. There is a black lesion to the medial first metatarsal head as well, no open wound. The lesion measured 1.4 x 1.4 cm. There were two [MEDICAL CONDITION] to the dorsal aspect of the foot located at the anterior ankle joint these [MEDICAL CONDITION] measured 1.2 x 1.2 cm laterally and 0.4 x 0.4 cm medially. There is a black lesion to the right posterior heel. It is not open and is not draining. It has a central eschar which feels thin and malleable measuring 4.4 x 8.2 cm. There is no evidence of periwound [DIAGNOSES REDACTED] or ascending [MEDICAL CONDITION] Several deep tissue injuries right foot... Pressure ulcer unstageable... The wounds to the right lower extremity were treated with skin repair cream. They were then offloaded with restalin foam and a posterior heel cup, in addition to the offloading boot, and were dressed with a dry sterile dressing consisting of kerlix and an ace bandage applied loosely. Orders were written for all wounds to the right foot to be dressed with [MEDICATION NAME], gauze, offloading foam and dry sterile dressing to be changed daily... Podiatry will follow." The resident's Medication Review Report (Physician Recapitulation orders), dated 3/12/14, documented in part: -"Blue Heel Float Boots when out of bed every shift...; -D/C (discontinue) Foot Board to bed; -D/C Foot tent; -Dress all wounds to right foot and ankle with [MEDICATION NAME] spray and dry sterile dressing daily. Every day shift for [MEDICAL CONDITION] To apply, spray [MEDICATION NAME] onto gauze and apply to wound. Offload wounds with foam padding, wrap with kerlix and ace bandages. On hold from 03/03/2014 to 03/06/2014; -Elevate foot rest every shift related to pressure ulcer unstageable; [MEDICAL CONDITION] Elevate the foot pedals/leg rests to ensure that the resident's foot do (sic) not touch the floor while up in the wheelchair. Right heel is not to touch the foot rest; -Heels to be offloaded while in bed by using pillow or bolster pad under legs and allowing heels to hang every shift for [MEDICAL CONDITION]; -Monitor left leg to ensure compression dressing is not too tight. every shift for [MEDICAL CONDITION]; Discontinued 3/4/14; -Offload right leg while in wheelchair. Right heel cannot rest on foot pedal. Consult PT (physical therapy) if necessary to help accomplish this. every day and evening shift for [MEDICAL CONDITION]; and - Zinc Oxide Ointment 20% and [MEDICATION NAME] Cream 0.1% to affected areas to lower left leg BID (twice daily) two times a day related to other [MEDICAL CONDITION]." The resident's IDPN documented in part: -3/4/14, "(Resident's physician) was in to see rsdt (resident) today and change dressings, new order received, 1)Dress all wounds to right foot and ankle with [MEDICATION NAME] spray and dry sterile dressing daily...3)DC (discontinue) compression dressings to right leg...; -3/5/14 at 7:07 AM, Late entry: On 3-2-14 Capillary refill was checked on the left and right foot of resident with a refill time of 4+ seconds per foot and the resident denied any pain to legs and feet; -3/5/14 at 9:05 AM, R(ight) lower extremity malleolus and lower, multiple areas of suspected deep tissue injury. No open areas at this time;" On 3/7/14, the Medical Director documented in part, "...On 3/02/14, the dressing was not changed and on 3/4/14, it was found that the resident developed multiple areas of a deep tissue injury related to the 2 layer compression wrap as well as his underlying vascular condition (PAD) ([MEDICAL CONDITION]) ...Multiple areas of deep tissue injury as described above secondary to 2 layer compression wrap. The initial recommendations for a 2 layer compression wrap were appropriate due to [MEDICAL CONDITION] and his underlying medical condition. The deep tissue injuries were related to Med error as well as patient's refusal of cares and medication." Note: The physician documented the resident refused medication, treatment, transfers to bed, incontinence care and placing pillows under his feet. He did not document the resident refused wound care or wrap changes, nor did the interdisciplinary notes or the wound care notes document the resident refused the ordered dressing change. The resident's IDPN documented in part: -3/9/14 at 9:40 PM, "Measurements for wounds on right foot done on 3/8/14. 6cm x 5cm, center of area is black with red around the edges. Area improving slowly. Area on interior side of the foot 6.3cm x 1.2cm, black with red and pink edges. Exterior side of foot 4cm x 1cm black areas with red and pink in the middle of the wound. All areas improving slowly. No areas are open all are closed; -3/10/14 at 1:48 PM, (The resident) has multiple ischemic-type wounds to his right foot. There is a pressure component as well as arterial insufficiency, and [MEDICAL CONDITION], using a Doppler, the pulses are faint and difficult to find. The resident has a history of refusing treatment, medications and cares. The medication refusals of the [MEDICATION NAME], led up to a weeping stasis [MEDICAL CONDITION], with 4+ [MEDICAL CONDITION]. treatment for [REDACTED]. The 4th day wrap change was not completed on 2/28. Although cap refill and general observation was conducted, x2 by licensed staff. As a result of this when the wraps were changed on 3/4 several dark ischemic areas were noted. These were classified as deep tissue injuries, of a mixed etiology, including pressure, arterial insufficiency and [MEDICAL CONDITION]. (The resident's physician) is in today to assess and treat the right foot of (the resident). We are continuing frequent turns, heel floating, and the foot board and foot cradle have been removed per (the resident's physician) order. There is a marked improvement in the resident's skin tone, and +2 capillary refill, that was assessed this morning. Please see (the resident's physician) dictation as it becomes available." On 3/10/14, the resident's physician documented in part: "...Patient was seen on entering the facility sitting in his wheelchair with the right foot resting on the footpedal of his wheelchair. Orders were specifically written for patient to be completely nonweight bearing to this foot including resting his foot on the foot pedal of his chair... Wounds to the right foot have all began draining serosanguinous fluid... Upon debridement of the wounds medially and laterally they were noted to be partial thickness with no evidence of purulence or ascending [MEDICAL CONDITION] Several deep tissue injuries right foot (sic) upon debridement are stage II ulcers. Unstageable ulcer right heel... Discuss with nursing staff the importance of following orders exactly. The foot pedal on the patient's wheelchair was removed and replaced with a device which allows the patients leg to rest on the stirrup but allows the heel to float..." The facility conducted an investigation of the incident and reported it to the Bureau of Facility Standards on 3/7/14 at 9:00 AM. That report, and included in part, "...In the process of checking these orders, and treatments, it was found that (LN #9), on 2/26/14, while working the cart on the East Hall, had not done the dressing change. She had entered a "9" (Note: "9" indicated see note) and the follow-up note read: that the dressing was to be done by (resident's physician). She made a medication error in the treatment, by not reading the actual order to ensure it was completed. So the treatment did not occur... On 3/2/14 (LN #10), also marked a "9" indicating that the treatment had not occured, due to "no supplies". The supplies were in a cabinet placed outside the supply room. He had not seen them. The medication error occurred because the dressing was not changed. A subsequent meeting with LN #10 this AM, indicated that he had not thought of removing the dressing, had not notified the physician, and had not included the supply issue in the 24 hour report. There were no emails to supply asking for wraps. LN #10 failed to recognize the underlining (sic) vascular condition of the legs. He also failed to notify management of the missing equipment, and he failed to notify management or supply of the dressing being held. Upon removing the wrap, (the resident) had a degradation in skin condition. There were multiple areas of deep tissue injury, with no open wounds. New treatment orders were written, and the compression wraps were (discontinued)... Medication error reports were completed. Staff members were individually counseled on the application of compression wraps and their potential to cause an increased risk in skin integrity impairment, particularly for those who have predisposing [DIAGNOSES REDACTED]." On 3/12/14 at approximately 1:45 PM, the DNS was interviewed and stated the resident had periodically refused his medications. He said, "That's why we ended up doing the treatment of [REDACTED]. (The resident's physician) was managing the left leg wraps and he would look at the right leg too when he was here. Then we had a med(ication) error. We did an investigation and reported it to the State... I classified it as vascular even though it obviously has a pressure component... He didn't have pressure on his heels before..." When the DNS was asked if he believed Resident #1's pressure wounds were preventable he said, "I don't think that he would have had a pressure injury if the wraps were taken care of, but with all of the other medical issues, we don't know." Additional information was received by the facility on 3/17/14 at 4:35 PM. Although the narrative and documentation contained information the resident has had a pressure ulcer on his heel and left lateral foot in 2012, he did not have documented pressure sores prior to the initiation of the pressure wrap on 3/4/14 to his right foot and ankle. Per the interpretive guidance at F314, "... the resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing." The narrative written by the facility documented, "The medical director's notes indicated that extreme caution should be taken when applying compression wraps." This was not carried out by the facility. The facility did not consistently document capillary refill, sensation or color of the feet, and the ordered dressing change was missed by the facility making the dressing change late by four days. Additionally, on 3/10/14, the physician documented the facility was not following orders to facilitate wound healing for the resident when he observed the resident's right heel resting on the foot rest. The facility documented, "During the time that the wraps were on the the patient refused medications and treatments as well as ADL cares." This was not supported by the documentation provided or facility treatment logs. There was no indication the resident refused dressing changes or cares at the time the pressure wrap dressing was missed. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission MDS, dated [DATE], documented: -BIMS (Brief Interview Mental Status) score: 11 - Moderately impaired. -Rejection of care- Behavior not exhibited. -Bed Mobility: 3-3 Extensive assistance, 2 person assistance. -Functional limitation in range of motion- Upper extremity: both sides. Lower extremity: both sides. -Risk of pressure ulcers-Yes. -Unhealed pressure ulcers- Stage 1 or higher- No. The resident's Braden scale -For Predicting Pressure Sore Risk, dated 2/6/14, documented: -Score: 20.0. Category: NA (not applicable). The resident's Admit/Annual Nursing assessment dated [DATE], documented: -Skin- "Foot Problems: No." -Illustrate [MEDICAL CONDITION], bruises, amputations, Etc: "3+ [MEDICAL CONDITION]" (lower legs), "Bruising" (right and left back side of forearm, and left side of upper back), "scab .5 x .2" (forehead) and "Scratch to back of left ear." The resident's Physician Active Orders, date range, 2/6/14 -3/31/14, documented: -"Offload B/L(bilateral) heels with bolster pad to allow heels to hang. Off load heels with offloading boots. every shift for blister." Revision date: 2/25/14 -"Order [MEDICATION NAME]. Dress wound to right heel with [MEDICATION NAME], 4 x 4 gauze and kerlix. Change every other day. OK to substitue (sic) [MEDICATION NAME] with [MEDICATION NAME] until [MEDICATION NAME] arrives. every day shift every other day for Blister." Revision date: 2/25/14 -"Weekly Skin Assessments as needed for [MEDICATION NAME] on shower day." Revision date: 2/6/14. The resident's Physician phone order, dated 3/13/14, documented: -"Offload bilateral heels with bolster pad while in bed. Heel float boots to be worn at all times." NOTE: The order for "Heel float boots to be worn at all times" was obtained after the boots were not consistently implemented, and the surveyor brought the concerns to the facility's attention. The resident's Care Plan documented: *Focus: "The resident has potential for impairment to skin integrity r/t (related to) [MEDICAL CONDITION], fragile skin, and immobility. "Date initiated: 2/21/14. *Interventions: -"Identify/document potential causative factors and eliminate/resolve where possible. "Date initiated: 2/21/14. -"The resident needs pressure reducing mattress to protect the skin while IN BED. (sic)" Date intimated: 2/21/2014. *Focus: "I require extensive, assistance in most care area R/T Musculoskeletal impairment, Activity Intolerance, Limited Mobility, Confusion, Impaired balance." Date initiated: 2/16/14. *Interventions: "The resident requires Skin inspection when providing cares and on bath days. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. "Date initiated: 2/21/14. NOTE: The resident's care plan did not document the physician ordered interventions dated 2/25/14, for the bolster pad to float bilateral heels and the offloading boots. The interventions documented in a Skin/Wound Progress note dated 2/23/14, to turn every 2 hours and prn (as needed), was not documented in the care plan. The physician progress notes [REDACTED]. -Chief complaint: "Blister right lateral heel." -Subjective: "Staff had noted over the weekend during a routine skin examination that a blister had formed on the lateral aspect of the right heel. Nursing placed the patient in a heel cup and offloading boots to offload the lesion. Nursing noted the patient usually wears slippers and does not wear shoes." -Objective: "Dermatologic: There is evidence of a trained blister to the lateral aspect of the patient's right foot measuring approximately 2 x 2 cm. (centimeters) some purpleish (sic) discoloration noted to the center of the wound. There is no evidence of [MEDICAL CONDITION] on the contralateral extremity." "Musculoskeletal: Rigidity noted to knee and hips with range of motion. Pain was elicited with internal rotation at bilateral hips. feet naturally rest and (sic) abducted position which appears to be cause of pressure/friction to the location of the lesion." -Assessment: "1. Friction blister vs. Deep tissue injury right heel. Diagnoses: [REDACTED]." -Plan: 1. "Patient was seen and evaluated." 2. "The wound was dressed with [MEDICATION NAME], dry sterile gauze and Kerlix." 3. "Orders were written for [MEDICATION NAME] spray and dry sterile dressing to be applied to wound QOD (every other day)." 4. "Orders were written for feet to be offloaded in offloading boots and bolster which will allow feet to float freely and not touch the bed." 5. "Will follow." The resident's weekly skin and wound assessment form dated 2/27/14 at 7:33 pm, documented: -Site: "Right heel." Type: "Blister." Length, Width, Depth: "2 cm x 2 cm." Stage: "Unstageable." -Care plan has been updated: The box was not checked. The resident's IDTP notes documented: *2/23/14 at 6:42 am - Skin/wound Progress note: "Wound location and Etiology: outer aspect of right heel. Assessment: 2 cm x 2 cm intact blood blister. no s/s (signs or symptoms) infection. no odor. no drainage. no pain." *2/23/14 at 1:40 pm - Nursing Note: "new blister found to right heel this am. hard, intact blister measures 2.1 cm by 2.2 cm and is not raised from the surface of the dermal layer surrounding it. denies pain to site. off load boots used to bed as resident calls for assistance with all transfers." *2/24/14 at 2:24 am - Nursing Note: "area to right heel conts (continues) to be healing well with no s/s of infection. no odor. no drainage. no c/o (complaint of) pain to site. cont to relieve pressure to right heel while in bed. cont to turn every 2 hours and prn (as needed). will cont to monitor." *2/24/14 at 10:34 pm - Nursing Note: "Dr. (physician's name) was in to see rsdt. (resident), new orders received,... Off load B/L heels with bolster pad to allow heels to hang..." *2/25/14 at 7:46 pm - Orders-Administration Note: "Bolster pad not arrived yet." NOTE: This note was written approximately 24 hours after the new Physician order [REDACTED]. *2/26/14 at 2:53 pm - Nursing Note: "Resident with dressing change to blister site on right heel. blister intact, 2 x 2.2 cm, no drainage." *2/26/14 9:23 pm - Orders-Administration Note: "Off load B/L heels with bolster pad to allow heels to hang. Off load heels with offloading boots. every shift for blister. not arrived yet." NOTE: This note was written over 48 hours after the new Physician order [REDACTED]. *2/27/14 at 2:27 am - Nursing Note: "bolster pad in place. heels off loaded bilat(eral) r/t right heel blister. drsg (dressing) to right heel CD&I (clean, dry and intact). No odor. will cont to monitor." *3/2/14 at 2:21 pm, Skin/Wound Progress Note: "Assessment: Resident with intact blister at 2 x 2.5 cm. No noted drainage. skin texture like leather. resident compliant with use of float boots and heel lift cushion." NOTE: The blister increased in size from initial 2 x 2 cm to 2 x 2.5 cm. The noted increase in size was approximately 9 days after the wound was first observed by staff and 7 days after the MD had ordered the heel lift cushion, and offload boots. *3/7/14 at 2:02 pm - Skin/wound Progress note: "Assessment: Skin check completed in shower. Resident continues with treatment to right heel blister, area intact. blister roof with leather feel. size 2 x 2 cm. resident compliant with heel float boots." The resident's physician progress notes [REDACTED]. -Chief complaint: "Follow up of lesion to right lateral heel." -Subjective: "Resident was seen today for follow-up of lesion to his right lateral heel." -Objective: "Dermatologic: There is still evidence of a drained blister to the lateral aspect of the patients right foot measuring approximately 2 x 2 cm. Some purpleish (sic) discoloration noted to the center of the lesion. While there is still [MEDICATION NAME] blood noted to the lesion, the lesion is essentially healed and is now primarily hyperkeratotic tissue." -Assessment: "1. Friction blister vs. Deep tissue injury right heel mostly resolved." -Plan: 1. "Patient was seen and evaluated." 2. "Continue offloading measures." 3. "Continue use of [MEDICATION NAME] and dry sterile dressing." On 3/11/14 at 8:15 am, the resident was in his w/c in his room. The resident's right foot had a blue offload boot in place. When the resident was asked about the boot, he stated, "It has a red spot on it." On 3/11/14 at 9:24 am, the resident was in bed asleep. The resident had blue offload boots to bilateral feet. The blue wedge pillow was behind the back of the legs, both feet were resting directly on the bed. On 3/11/14 at 12:39 pm, the resident was at the nurse's station watching television. The right foot had a blue offload boot in place. The right foot was in a dependent position resting on the w/c (wheelchair) foot rest. On 3/11/14 at 1:45 pm, the resident was awake in bed. The resident had a blue offload boot on the right foot. The wedge pillow was in place and bilateral heels were floated. When the surveyor asked the resident was if he had pain in the right heel he stated, "No." On 3/11/14 at 3:24 pm, the resident was in bed asleep. The resident had blue offload boots to bilateral feet, and the heels were floated off the wedge pillow. On 3/12/14 at 11:14 am, the resident was up in his w/c at the nurse's station with an offload boot in place, on the resident's right foot. On 3/12/14 at 2:55 pm, the resident was awake in bed. The right foot had a blue offload boot on it and the left foot had a sock. The blue wedge was positioned below the knees of the resident's legs, both feet were directly on the bed. The resident was asked if he had pain in the right heel he stated, "Sometimes I can feel it." On 3/12/14 at 3:10 pm, LN #6 was asked about the pressure sore to the resident's right heel, she stated, "We had a blister show up on that heel. Dr. (physician's name) was the attending (physician) for it. It's like a callous on the heel part. It had fluid but it sealed itself." When asked what caused it, the LN #6 stated, "Initially when he came here he slept with his feet filleted." The LN #6 then demonstrated the heels together with the feet out. On 3/12/14 at 4:25 pm, the resident was asleep on his right side. The right foot had a blue offload boot in place, and the left foot had a white sock on it. The blue wedge pillow was directly under the feet and the heels were resting on the wedge pillow. At 4:27 pm, the RN Manager LN #7, observed the position of the feet and agreed the heels were not floated. LN#7 was unable to adjust the wedge pillow to float the heels and stated she would get a CNA to help her. On 3/12/14 at 5:05 pm, the surveyor observed the resident in his w/c in the dining room. The resident's blue offload boot was off of the resident's right foot and was on the floor behind the w/c's foot peg. The right foot was resting on the w/c's foot peg with a white sock on. LN #8 approached the resident and stated, "(Resident's name) can I put your boot back on," and the resident stated "Yeh." On 3/13/14 at 8:10 am, the resident was asleep on the right side. The resident's bilateral feet had socks on them, the offload boots were not in place. The blue wedge pillow was positioned just below the resident's knees, and both feet were in direct contact with the bed. At 8:15 am LN #7 verified the placement of the feet and the missing boots with the surveyor. LN #6 entered the room and stated, "I was under the understanding if the heels are floated, we did not need the boots." On 3/13/14 at 8:39 am, LN #7 discussed the order for the boots and the wedge with the surveyor. LN #7 stated, "The order was more general and the nurses read more in to it. I am getting a clarified order that will state at all times," for the use of the boots. When asked if the care plan had been updated since the new wound to the heel, LN#7 stated, "It wasn't updated and I am going to do that." On 3/13/14 at 9:40 am, LN#6 was observed changing the dressing to the right heel pressure ulcer. LN #6 stated the dressing change is, "every other day." After touching the area, LN#6 stated, "it is leathery." LN#6 then measured the wound and stated it measured, "3 cm long by 2 cm wide, purple edges, yellow center, with one point where the purple comes to the center." NOTE: the wound had increased from the initial assessment of 2 cm x 2 cm to 3 cm x 2 cm.) Resident #6 was discovered with blister to the right lateral heel on 2/24/14 that measured 2cm X 2cm. On 2/25/14, Resident #6 ' s physician ordered relief of pressure to the resident ' s bilateral heels via a bolster pad and that offloading (pressure) boots were to be on the resident ' s feet every shift, as well as whenever the resident was in bed. None of these interventions ordered by Resident #6 ' s physician were included in the resident ' s Care Plan, and IDT Notes documented the bolster pad, ordered by the resident ' s physician on 2/25/14, was not put into place until 2/27/14, two days after it was ordered. On 3/13/14, the wound was documented as measuring 3 x 2cm. During the facility ' s annual recertification and licensure survey, surveyors observed Resident #6 without one or more of the physician-ordered pressure-relieving interventions in place on nine separate occasions. 3. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Quarterly MDS, dated [DATE], documented: -BIMS score: 9 - Moderately impaired. -Rejection of cares- Behavior not exhibited. -Functional limitation in range of motion- Upper extremity: both sides. Lower extremity: both sides. -Risk of pressure ulcers- Yes. -Unhealed pressure ulcer- No. The resident's Braden Scale- for Predicting Pressure Sore Risk, dated 10/19/13, documented: -Score- 14: Moderate risk. The resident's Physician phone order, dated 2/10/14 at 2:16 pm, documented: -"Clean area to inner left little finger, apply small piece of [MEDICATION NAME], apply tape to hold in place. Change twice a weel (sic) on Mondays and Fridays every day shift every Mon., Fri for open wound." The resident's Physician phone order dated 2/13/14 at 2:23 pm, documented: -Finger separator is to be on at all times, to be removed for skin check every shift. every shift for [MEDICATION NAME]." The resident's physician progress notes [REDACTED]. -Physical Exam: "His hands show contractures. He recently had a small ulceration between the webspace of the fifth and fourth digit. This is healed and he has had a new brace fitted." The resident's

Based on review of the facility's abuse policy, review of investigations, review of personnel files, record review, and staff interview, it was determined the facility failed to ensure all allegations of abuse, neglect and/or mistreatment were immediately reported, residents were immediately protected, allegations were thoroughly investigated, and appropriate corrective action was taken. That failure directly impacted 3 of 17 residents (Residents #10, #16 and #17) involved in significant incidents. This resulted in placing Resident #17 in immediate jeopardy with potential for serious harm or impairment due to ongoing abuse. Additionally, this resulted in the potential for on-going abuse and mistreatment to occur to Residents #10 and #16 without immediate protection and notification, thorough investigations and appropriate corrective action being taken. The findings include: 1. The facility's Resident Abuse/Neglect policy, undated, defined verbal abuse as "any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance to describe residents, regardless of their age, ability to comprehend or disability." Additionally, sexual abuse "includes, but is not limited to, sexual harassment, sexual coercion or sexual assault." a. On 2/14/13 at 12:40 p.m., four investigations from the past year were chosen at random for review. A Report of Investigation, undated, contained an allegation of abuse against LN # 19 to Resident #17 on 8/5/12. The statement from CNA #8, undated, stated "I witnessed a situation between (Resident #17) and (LN #19). I saw and heard (Resident #17) yelling at someone at the Nurse's station...When I approached the Nurse (sic) station I saw (LN #19) standing outside of the Nurse (sic) station...she was laughing very loud and was taunting and mocking (Resident #17). (Resident #17) was yelling back at her and called her a 'f***ing b***ard' and threw an ice bag he had wrapped around his neck at her and saying to (LN #19) "stick it up your a*s" and gave her the middle finger. (LN #19) just laughed at him even louder and told (Resident #17) 'that she doesn't like to do it that way'...There were 2 other (LN)'s at the Nurse's station (LN #6) who was sitting charting and (LN #9)...neither of them interviend (sic) or looked up." On 2/14/13 from 3:05 - 3:30 p.m., CNA #8 was asked about the 8/5/12 incident. CNA #8 stated she reported the incident verbally to the DON on 8/6/12 or 8/7/12. CNA #8 stated the DON requested that it be put in writing, which she completed and gave to the DON between 8/7/12 and 8/9/12. On 2/14/13 from 4:10 - 4:56 p.m., the DON stated she talked with LN #19 before this incident and told her if she needed help redirecting Resident #17, to let her know. The Report of Investigation did not include any information related to LN #6 and LN #9 or the DON. b. The Report of Investigation contained documentation of seven employee interviews conducted by LSW #1, undated and untimed. The interviews documented that employees were aware and reported to management staff, LN #19's ongoing abuse of Resident #17 with no action being taken by the facility, as follows: - Worker #1 stated " ...she's caught (LN #19) cussing at (Resident #17) in the past and had to step in to actually redirect (LN #19). She notes (LN #19) continues to do things which taunt (Resident #17)...This particular staff member notes they have warned (LN #19) about her actions to no avail." - "Worker #2 noted much of the same above...worker #2 (sic) stated (LN #19) will flirt with (Resident #17) and then tell him to leave her alone when he wants to continue the contact...When asked, worker #2 noted name-calling, the flirting, and the off-hours spent between (Resident #17) and (LN #19) as being very unprofessional." The documentation of Worker #2 ' s interview did not include specific names called, what Worker #2 meant by " flirting " , and it could not be determined what exactly took place during those " off-hours. " - "Worker #3" stated the only thing she had witnessed was the 'Cat & Mouse' game between "(Resident #17) and (LN #19)." The documentation of Worker #3 ' s interview did not include any additional information describing the " cat & mouse " game. - "Worker #4 was relieved to be talking about this issue of (Resident #17) and (LN #19) and noted frustration over past attempts at getting someone to do anything about this. She spoke of this relationship/issue going back at least a year and a half and noted other co-workers trying to tell (LN #19) or warn her of her inappropriate actions with him...She states (LN #19) gets very obnoxious when others try and warn her of her actions and will often yell, cuss, or just make things harder on the aids (sic). She also stated she and others have said things to management but, still are (sic) no changes in (LN #19)'s behaviors. She notes (LN #19) appears to love the attention and drama she gets from (Resident #17). She also reportedly jokes in inappropriate and vulgar ways. When asked for an example, she noted (LN #19) and (Resident #17) will speak about sexual things/acts. (LN #17) is said to have been having one of these conversations with (Resident #17) when she left the room saying, "You couldn't please me." She also spoke of the other extreme where (LN #19) is now threatening to harm (Resident #17) if he doesn't leave her alone. More specifically, (LN #19) was overheard telling (Resident #17) she would break his hand if he didn't get away from her. She's also been heard telling (Resident #17) how he ' disgusts her. ' On another occasion (LN #19) was heard telling (Resident #17) how he ' stinks ' while she was caring for him. Worker #4 is concerned with all the attention being given to (Resident #17) for his behaviors when she finds (LN #19) to be at fault for encouraging the relationship with such inappropriate behavior in the first place." The interview did not contain documentation of which management staff Worker #2 had reported to in the past. - "Worker #5 was very upset over the lack of attention from management regarding this particular issue. They noted the problems with (LN #19) and (Resident #17) have been going on for well over a year and there have been no noticeable changes in (LN #19)'s behavior. Because of this, many staff have simply given up on the idea of management taking notice and have quit reporting. Also noted by worker #5 (sic) were the many times (LN #19) would come to work early just to sit with (Resident #17) in his room. The conversations were noted as being flirtatious and inappropriate but warnings from staff were said to be ignored by (LN #19)...Worker #5 reports if (LN #19) isn't flirting with (Resident #17) she's calling him an 'a*s' or some other name, yelling at him to get away from her even though he's not purposefully seeking her attention, or just taunting him with gestures and looks. These things are said to have often left (Resident #17) crying and feeling confused." - "Worker #7 was very reluctant to speak with this worker and at one point asked if she and others were going to lose their jobs over this relationship between (Resident #17) and (LN #19). When asked why anyone would be fired, worker #7 (sic) stated people have been afraid to speak up for fear of retaliation by other nurses in charge or even management who, 'clearly like (LN #19). ' When asked what she meant by management, worker #7 (sic) gave the names of (DON) and (RN Manager)...She spoke of the relationship between (Resident #17) and (LN #19) as being wrong and weird. She said it's been totally unprofessional from one extreme to the other. She explained that (LN #19) would spend hours sitting in (Resident #17)s (sic) room with him after her shift was over. They'd laugh and talk about getting married and having children together. She said they'd do this in the common area as well as if (LN #19) needed other people to know (Resident #17) was in love with her. She then noted how (LN #19) would be totally opposite and just get mean with (Resident #17) to the point he would cry." On 2/15/13 from 9:18 - 9:38 a.m., the RN Manager stated her staff would casually tell her that the relationship between Resident #17 and LN #19 was inappropriate, but no one ever came to her directly with " grave concerns. " On 2/14/13 from 4:10 - 4:56 p.m., the DON stated talked with LN #19 before and told her if she needed help redirecting Resident #17, to let her know. On 2/14/13 from 4:10 - 4:56 p.m., the Administrator stated she was unaware of the allegation against LN #19 until the statement written by CNA #8 was placed on her desk on 8/15/12. c. The Report of Investigation did not document how Resident #17 was protected from ongoing abuse. Additionally, during the course of the survey, staff were interviewed about LN #19 with the following results: - Employee #14 stated LN #19's family member was a resident at the facility and LN #19 still visited him. She said that when LN #19 visited, Resident #17 cried and got very upset. Employee #14 requested that arrangements be made for LN #19 to visit her family member in a private area, but nothing was done with her request. - Employee #20 stated at one point, Resident #17 was put on suicide watch due to the interactions with LN #19. She stated since LN #19's employment ended, LN #19 had been back to the facility to visit her family member and continued to tease Resident #17 in a sexual nature. Employee #20 said she reported multiple times to the DON that LN #19 was responsible for the inappropriate relationship, but nothing was done. - Employee #13 stated LN #19 had visited the facility to visit her family member one or two times since her employment with the facility ended, and the visits upset Resident #17. - LSW #1 stated during an interview on 2/14/13 from 6:15 - 6:40 p.m., he had not witnessed firsthand LN #19 ' s post-employment visits, but had received reports that Resident #17 was upset for quite some time after LN #19 visited the facility. LSW #1 stated LN #19 should have guidelines or supervision in place to visit, but as far as he knew, she did not. - LSW #2 was interviewed on 2/15/13 from 9:39 - 10:57 a.m. LSW #2 stated she had heard that Resident #17 was tearful during LN #19 ' s continued visits to the facility. LSW #2 stated when LN #19 was not visiting; Resident #17 was in good spirits. LSW #2 stated she was unaware of any guidelines for LN #19 to make arrangements to visit the facility and stated she herself, did not have any responsibilities if LN #19 visited (such as notifying the Administrator, escorting LN #19, etc.). - The RN Manager stated, during an interview on 2/15/13 from 9:18 - 9:38 a.m., her staff would casually tell her that the relationship between Resident #17 and LN #19 was inappropriate, but no one ever came to her directly with " grave concerns. " - The Administrator stated, during an interview on 2/14/13 from 4:10 - 4:56 p.m., in the past she heard staff occasionally say, " (Resident #17) ' s going to see (LN #19), " however, she was unaware of the extent of the situation until the Report of Investigation was completed in August 2012. Further, the Administrator said she was responsible for placing employees on administrative leave through communication with Human Resources and allowing LN #19 to continue working during the course of the investigation was her decision. d. The Report of Investigation documented the investigation was not initiated until 8/21/12. No explanation for the time delay between the 8/5/12 incident until the initiation of the investigation could be found. e. The Report of Investigation did not include documentation that Resident #17, the DON and the RN Manager were interviewed. f. The allegation of abuse by LN #19 was not reported to the Bureau of Facility Standards as required in Informational Letter #2005-1. g. The Report of Investigation did not include evidence that corrective action was taken with all employees including management staff who were aware of LN#19's ongoing abuse to Resident #17. Review of LN #19 ' s personnel file showed that LN #19 was terminated 9/6/12 due to the results of the investigation. Finally, employees of the facility including management staff (who were aware of LN#19's ongoing abuse to Resident #17 during her employment) were also aware of LN #19's current contact with Resident #17 during her visits. The survey team read, and provided in writing, the following statement on 2/15/13 at 8:45 a.m.: " During an Idaho State recertification survey, initiated 2/11/13 a deficient practice was identified at 483.13(c)(2), 483.13(c)(3), 483.13(c)(4) 483.13(c). This failed practice resulted in serious harm constituting immediate jeopardy. The Idaho State survey team determined the facility failed to protect a resident from further abuse when they allowed a facility staff member, who was terminated for the abuse, enter the facility without structured guidelines and/or supervision. The staff member was allowed to visit a family member and former co-workers without protecting the resident from abuse. In addition, the facility failed to investigate, thoroughly and immediately, all allegations of abuse, protect the resident during the investigation, and report the allegation and the investigation to the appropriate agencies as required. These failed practices were brought to the attention of the facility Administrator and Director of Nursing on 2/15/13 at 0845. The facility was provided specific details of these failures. Idaho State Veteran ' s Home - Lewiston should begin immediate removal of the risk to individuals and immediately implement corrective measures to prevent repeat jeopardy situations. " The document was signed by the survey team, the Administrator, and the DON. NOTE: An acceptable Plan of Correction was submitted on 2/15/13 at 2:15 p.m. and the immediate jeopardy was abated. 2. An Incident Investigation, undated, summarized an investigation conducted from 8/13/12 - 8/15/12 regarding an allegation of abuse on Resident #16, during a shower on 8/1/12 by LN #19 and CNA #20. Resident #16 ' s Resident Facesheet, undated, documented a [AGE] year old male whose [DIAGNOSES REDACTED]. a. LN #19 was placed on administrative leave 8/14/12 for protection of the residents, however, CNA #20 was not. When asked during an interview on 2/19/13 from 2:50 - 3:12 p.m., the Administrator stated CNA #20 was not placed on administrative leave because once statements clarifying the allegation were received, the focus was placed on LN #19. b. CNA #3 witnessed the shower on 8/1/12 and reported the incident to LN #4 on 8/12/13. LN #4 then reported the incident to the Administrator on 8/13/13. However, the Incident Investigation did not contain documentation that CNA #3 or LN #4 were retrained on the abuse policy, including immediate protection of residents or immediate reporting. When asked, the Administrator stated during an interview on 2/19/13 from 2:50 - 3:12 p.m. she carried a facility phone 24 hours a day, seven days a week to facilitate immediate reporting. She stated she would check personnel files for documentation of the abuse policy, however, the facility failed to provide any additional documentation. 3. Resident #10 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 10/15/12, coded: * Understood and usually understands * BIMS of 9 indicating moderately impaired cognitive skills for daily decision making * No signs or symptoms of [MEDICAL CONDITION] present * Physical behavioral symptoms directed toward others occurred 1 to 3 days during the 7 day look back period * Verbal behavioral symptoms directed toward others occurred 4 to 6 days during the 7 day look back period * Mood score for depression was zero indicating no signs or symptoms of depression during the 14 day look back period Resident #10's Physician order [REDACTED]. Resident #10's Plan of Care documented the problem, dated 6/18/09, "AIA (unknown)." Interventions included, "...Provide opportunity for communication/socialization during each contact." Under the problem, "Ineffective Individual coping," dated 6/10/09, interventions included, "...1:1, diversional activities ...validation, redirection. " On 12/13/12, a Social Services Progress Notes entry (untimed), recorded by LSW #1, documented, "Staff have shared info(rmation) about (Resident #10) having had a verbal altercation w/staff (with staff) during dinner last night (12/12/12). He separately threatened physical harm and the staff responded inappropriately, but then walked away. ...Social Services will speak with & remind him of not only the consequences of his action but his responsibility to respect staff and other residents." A second untimed note, recorded on 12/13/12 by LSW #1, documented, "Spoke w/(Administrator's name) who agreed (Resident #10) has now escalated his verbal abuse to physical threats (with) staff. With 2 staff having reacted as shared their inability to cont(inue) working or under this abuse, it may be time to look at transferring (Resident #10) to another facility. ..." During an interview with Employee #20 (E-20), the employee was asked about abuse, in general, in the facility. E-20 said that sometime recently, at least during the last year, E-20 knew about verbal abuse between Resident #10 and a co-worker. E-20 stated, "He (Resident #10) wanted (staff member) to do something. The (staff member) started swearing at (Resident #10) and (the staff member) got fired." The verbal interaction between Resident #10 and a staff member, which took place on 12/12/12 according to LSW #1, was not brought to the attention of the LSW or the Administrative staff until the next day, 12/13/12. The Administrator was notified by LSW #1 of the alleged abuse on 12/13/12. The Bureau of Facility Standards did not record any call to the department's hotline and did not record any faxed report of a completed investigation of the incident of alleged abuse on 12/12/12 as required in Informational Letter #2005-1. The facility failed to report the incident between Resident #10 and a staff member to the Bureau of Facility Standards as required by State law and federal regulations.

Based on policy review and staff interview, it was determined the facility failed to develop and operationalize policies and procedures that prohibited mistreatment, neglect, and abuse of residents and misappropriation of resident property. That failure directly impacted 3 of 17 residents (Residents #10, #16 and #17) involved in significant incidents. This resulted in placing Resident #17 in immediate jeopardy with potential for serious harm or impairment due to ongoing abuse. Additionally, this resulted in the potential for on-going abuse and mistreatment to occur to Residents #10 and #16 without immediate protection and notification, thorough investigations and appropriate corrective action being taken. The findings include: 1. The facility's Resident Abuse/Neglect policy, undated, defined verbal abuse as "any use of oral, written or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance to describe residents, regardless of their age, ability to comprehend or disability." Additionally, sexual abuse "includes, but is not limited to, sexual harassment, sexual coercion or sexual assault." a. On 2/14/13 at 12:40 p.m., four investigations from the past year were chosen at random for review. A Report of Investigation, undated, contained an allegation of abuse against LN # 19 to Resident #17 on 8/5/12. The statement from CNA #8, undated, stated "I witnessed a situation between (Resident #17) and (LN #19). I saw and heard (Resident #17) yelling at someone at the Nurse's station...When I approached the Nurse (sic) station I saw (LN #19) standing outside of the Nurse (sic) station...she was laughing very loud and was taunting and mocking (Resident #17). (Resident #17) was yelling back at her and called her a 'f***ing b***ard' and threw an ice bag he had wrapped around his neck at her and saying to (LN #19) "stick it up your a*s" and gave her the middle finger. (LN #19) just laughed at him even louder and told (Resident #17) 'that she doesn't like to do it that way'...There were 2 other (LN)'s at the Nurse's station (LN #6) who was sitting charting and (LN #9)...neither of them interviend (sic) or looked up." On 2/14/13 from 3:05 - 3:30 p.m., CNA #8 was asked about the 8/5/12 incident. CNA #8 stated she reported the incident verbally to the DON on 8/6/12 or 8/7/12. CNA #8 stated the DON requested that it be put in writing, which she completed and gave to the DON between 8/7/12 and 8/9/12. On 2/14/13 from 4:10 - 4:56 p.m., the DON stated she talked with LN #19 before this incident and told her if she needed help redirecting Resident #17, to let her know. The Report of Investigation did not include any information related to LN #6 and LN #9 or the DON. b. The Report of Investigation contained documentation of seven employee interviews conducted by LSW #1, undated and untimed. The interviews documented that employees were aware and reported to management staff, LN #19's ongoing abuse of Resident #17 with no action being taken by the facility, as follows: - Worker #1 stated " ...she's caught (LN #19) cussing at (Resident #17) in the past and had to step in to actually redirect (LN #19). She notes (LN #19) continues to do things which taunt (Resident #17)...This particular staff member notes they have warned (LN #19) about her actions to no avail." - "Worker #2 noted much of the same above...worker #2 (sic) stated (LN #19) will flirt with (Resident #17) and then tell him to leave her alone when he wants to continue the contact...When asked, worker #2 noted name-calling, the flirting, and the off-hours spent between (Resident #17) and (LN #19) as being very unprofessional." The documentation of Worker #2 ' s interview did not include specific names called, what Worker #2 meant by " flirting " , and it could not be determined what exactly took place during those " off-hours. " - "Worker #3" stated the only thing she had witnessed was the 'Cat & Mouse' game between "(Resident #17) and (LN #19)." The documentation of Worker #3 ' s interview did not include any additional information describing the " cat & mouse " game. - "Worker #4 was relieved to be talking about this issue of (Resident #17) and (LN #19) and noted frustration over past attempts at getting someone to do anything about this. She spoke of this relationship/issue going back at least a year and a half and noted other co-workers trying to tell (LN #19) or warn her of her inappropriate actions with him...She states (LN #19) gets very obnoxious when others try and warn her of her actions and will often yell, cuss, or just make things harder on the aids (sic). She also stated she and others have said things to management but, still are (sic) no changes in (LN #19)'s behaviors. She notes (LN #19) appears to love the attention and drama she gets from (Resident #17). She also reportedly jokes in inappropriate and vulgar ways. When asked for an example, she noted (LN #19) and (Resident #17) will speak about sexual things/acts. (LN #17) is said to have been having one of these conversations with (Resident #17) when she left the room saying, "You couldn't please me." She also spoke of the other extreme where (LN #19) is now threatening to harm (Resident #17) if he doesn't leave her alone. More specifically, (LN #19) was overheard telling (Resident #17) she would break his hand if he didn't get away from her. She's also been heard telling (Resident #17) how he ' disgusts her. ' On another occasion (LN #19) was heard telling (Resident #17) how he ' stinks ' while she was caring for him. Worker #4 is concerned with all the attention being given to (Resident #17) for his behaviors when she finds (LN #19) to be at fault for encouraging the relationship with such inappropriate behavior in the first place." The interview did not contain documentation of which management staff Worker #2 had reported to in the past. - "Worker #5 was very upset over the lack of attention from management regarding this particular issue. They noted the problems with (LN #19) and (Resident #17) have been going on for well over a year and there have been no noticeable changes in (LN #19)'s behavior. Because of this, many staff have simply given up on the idea of management taking notice and have quit reporting. Also noted by worker #5 (sic) were the many times (LN #19) would come to work early just to sit with (Resident #17) in his room. The conversations were noted as being flirtatious and inappropriate but warnings from staff were said to be ignored by (LN #19)...Worker #5 reports if (LN #19) isn't flirting with (Resident #17) she's calling him an 'a*s' or some other name, yelling at him to get away from her even though he's not purposefully seeking her attention, or just taunting him with gestures and looks. These things are said to have often left (Resident #17) crying and feeling confused." - "Worker #7 was very reluctant to speak with this worker and at one point asked if she and others were going to lose their jobs over this relationship between (Resident #17) and (LN #19). When asked why anyone would be fired, worker #7 (sic) stated people have been afraid to speak up for fear of retaliation by other nurses in charge or even management who, 'clearly like (LN #19). ' When asked what she meant by management, worker #7 (sic) gave the names of (DON) and (RN Manager)...She spoke of the relationship between (Resident #17) and (LN #19) as being wrong and weird. She said it's been totally unprofessional from one extreme to the other. She explained that (LN #19) would spend hours sitting in (Resident #17)s (sic) room with him after her shift was over. They'd laugh and talk about getting married and having children together. She said they'd do this in the common area as well as if (LN #19) needed other people to know (Resident #17) was in love with her. She then noted how (LN #19) would be totally opposite and just get mean with (Resident #17) to the point he would cry." On 2/15/13 from 9:18 - 9:38 a.m., the RN Manager stated her staff would casually tell her that the relationship between Resident #17 and LN #19 was inappropriate, but no one ever came to her directly with " grave concerns. " On 2/14/13 from 4:10 - 4:56 p.m., the DON stated talked with LN #19 before and told her if she needed help redirecting Resident #17, to let her know. On 2/14/13 from 4:10 - 4:56 p.m., the Administrator stated she was unaware of the allegation against LN #19 until the statement written by CNA #8 was placed on her desk on 8/15/12. c. The Report of Investigation did not document how Resident #17 was protected from ongoing abuse. Additionally, during the course of the survey, staff were interviewed about LN #19 with the following results: - Employee #14 stated LN #19's family member was a resident at the facility and LN #19 still visited him. She said that when LN #19 visited, Resident #17 cried and got very upset. Employee #14 requested that arrangements be made for LN #19 to visit her family member in a private area, but nothing was done with her request. - Employee #20 stated at one point, Resident #17 was put on suicide watch due to the interactions with LN #19. She stated since LN #19's employment ended, LN #19 had been back to the facility to visit her family member and continued to tease Resident #17 in a sexual nature. Employee #20 said she reported multiple times to the DON that LN #19 was responsible for the inappropriate relationship, but nothing was done. - Employee #13 stated LN #19 had visited the facility to visit her family member one or two times since her employment with the facility ended, and the visits upset Resident #17. - LSW #1 stated during an interview on 2/14/13 from 6:15 - 6:40 p.m., he had not witnessed firsthand LN #19 ' s post-employment visits, but had received reports that Resident #17 was upset for quite some time after LN #19 visited the facility. LSW #1 stated LN #19 should have guidelines or supervision in place to visit, but as far as he knew, she did not. - LSW #2 was interviewed on 2/15/13 from 9:39 - 10:57 a.m. LSW #2 stated she had heard that Resident #17 was tearful during LN #19 ' s continued visits to the facility. LSW #2 stated when LN #19 was not visiting; Resident #17 was in good spirits. LSW #2 stated she was unaware of any guidelines for LN #19 to make arrangements to visit the facility and stated she herself, did not have any responsibilities if LN #19 visited (such as notifying the Administrator, escorting LN #19, etc.). - The RN Manager stated, during an interview on 2/15/13 from 9:18 - 9:38 a.m., her staff would casually tell her that the relationship between Resident #17 and LN #19 was inappropriate, but no one ever came to her directly with " grave concerns. " - The Administrator stated, during an interview on 2/14/13 from 4:10 - 4:56 p.m., in the past she heard staff occasionally say, " (Resident #17) ' s going to see (LN #19), " however, she was unaware of the extent of the situation until the Report of Investigation was completed in August 2012. Further, the Administrator said she was responsible for placing employees on administrative leave through communication with Human Resources and allowing LN #19 to continue working during the course of the investigation was her decision. The Administrator failed to protect Resident #17 from ongoing abuse. Upon conclusion of the investigation, the Administrator terminated LN #19 on 9/6/12. d. The Report of Investigation documented the investigation was not initiated until 8/21/12. No explanation for the time delay between the 8/5/12 incident until the initiation of the investigation could be found. e. The Report of Investigation did not include documentation that Resident #17, the DON and the RN Manager were interviewed. f. The allegation of abuse by LN #19 was not reported to the Bureau of Facility Standards in Informational Letter #2005-1. g. The Report of Investigation did not include evidence that corrective action was taken with all employees including management staff who were aware of LN#19's ongoing abuse to Resident #17. Finally, employees of the facility including management staff (who were aware of LN#19's ongoing abuse to Resident #17 during her employment) were also aware of LN #19's current contact with Resident #17 during her visits. The survey team read, and provided in writing, the following statement on 2/15/13 at 8:45 a.m.: " During an Idaho State recertification survey, initiated 2/11/13 a deficient practice was identified at 483.13(c)(2), 483.13(c)(3), 483.13(c)(4) 483.13(c). This failed practice resulted in serious harm constituting immediate jeopardy. The Idaho State survey team determined the facility failed to protect a resident from further abuse when they allowed a facility staff member, who was terminated for the abuse, enter the facility without structured guidelines and/or supervision. The staff member was allowed to visit a family member and former co-workers without protecting the resident from abuse. In addition, the facility failed to investigate, thoroughly and immediately, all allegations of abuse, protect the resident during the investigation, and report the allegation and the investigation to the appropriate agencies as required. These failed practices were brought to the attention of the facility Administrator and Director of Nursing on 2/15/13 at 0845. The facility was provided specific details of these failures. Idaho State Veteran ' s Home - Lewiston should begin immediate removal of the risk to individuals and immediately implement corrective measures to prevent repeat jeopardy situations. " The document was signed by the survey team, the Administrator, and the DON. NOTE: An acceptable Plan of Correction was submitted on 2/15/13 at 2:15 p.m. and the immediate jeopardy was abated. 2. The facility's Administrator was asked for the policy related to abuse and neglect on 2/14/13 at approximately 11:20 a.m. On 2/14/13 at 2:00 p.m., the facility's Administrator provided the survey team with a documented titled Resident Abuse/Neglect. When asked during a telephone interview on 2/19/13 at approximately 3:00 p.m., the Administrator stated the Resident Abuse/Neglect policy was put in place sometime in November 2011. The policy was reviewed and was not sufficient to ensure residents were not subjected to mistreatment, neglect, abuse, and misappropriation of their property, as follows: a. Under the section titled Policy/Purpose, it stated residents had a right to be free from corporal punishment. Corporal punishment was not defined. b. Under the section titled Definitions, it listed Sexual Abuse, Physical Abuse, and Mental Abuse. However, definitions for sexual, physical, and mental abuse were not included. c. Injuries of an unknown origin, resident-to-resident abuse, and self-injurious behavior were not included under the section titled Definitions. d. Under the section titled Implementation, it stated "Any person who has knowledge of any act of abuse, neglect, or misappropriation of resident property shall report such information to their immediate supervisor ...who in turn, shall immediately report such information to the home administrator." As stated, immediate intervention and protection of the resident was not provided. Additionally, the policy did not include information related to immediately suspending the alleged staff and timely notification of family members and/or legal representatives. e. Under the section titled Implementation, the policy stated "Criminal history checks shall be completed on all staff employed at (the facility)." The policy did not contain information related to when and where criminal history checks were to be completed, fingerprint requirements, supervision requirements until criminal history checks were completed, and procedures to be taken if a criminal history check came back with offenses that would prohibit employment. Additionally, the policy did not include information related to obtaining information from previous employers and/or current employers. f. Under the section titled Implementation, it stated "All alleged violations involving mistreatment, abuse or neglect will be thoroughly investigated by the facility under the direction of the Administrator and in accordance with state law." The policy did not include timelines for conducting an investigation and what was to be included in an investigation (i.e., witness statements, resident interview, etc.). Additionally, there was no information as to what to do if the alleged staff was the Administrator. g. Under the section titled Implementation, it stated "The facility will ensure that further potential abuse will not occur while the investigation is in progress. Any employee under investigation for violation of this policy shall be suspended from employment ..." The policy did not include information on how the facility would ensure potential abuse did not occur and there were no timeframes associated with suspending an employee. h. Under the section titled Implementation, it stated "The Administrator or his designee shall report to the state licensing authority ..." The policy did not include information on who was responsible for reporting if the alleged staff was the Administrator or his designee. The policy stated "These shall be reported to the appropriate officials within the time frames established by the Bureau of Facility Standards." The policy did not include the specific timeframes. The policy stated "If a law violation has occurred, the report of such violation shall be made immediately ..." The policy did not include information as was constituted a law violation. i. Under the section titled Implementation, it stated "based on the results of the facility investigation, appropriate disciplinary action will be taken, up to and including termination of an employee." The policy did not include information related to corrective action being taken to prevent the reoccurrence of abuse. j. Under the section titled Investigating and Reporting, it stated "The Administrator of (the facility), or the Acting Administrator in his absence, shall be responsible for directing the investigation and complying with all reporting requirements." The policy did not include information as to what to do if the alleged staff was the Administrator and/or the Acting Administrator. Additionally, there was no specific timeframes associated with "complying with all reporting requirements." k. Under the section titled Training, it stated "The content of this training shall include identifying appropriate interventions in dealing with aggressive and/or catastrophic reactions of residents ..." However, under the section titled Prevention, it stated "Careful attention will be give (sic) to all residents during the assessment and care planning processes for residents who may have special needs because of behaviors such as aggressiveness, catastrophic reactions, self-injury, nonverbal communication, or those who require heavy or total nursing care. These residents are to be viewed as especially vulnerable and deserving on ongoing protection." The policy did not include information related to training staff on residents' special needs including self-injury, nonverbal communication, or those who require heavy or total nursing care to ensure ongoing protection was provided. l. Under the section titled Identification, it stated "All events which warrant reporting via the facility Incident/Accident reporting system shall be tracked so as to be able to identify suspicious events, occurrences, patterns or trends that may constitute abuse or neglect. The facility administration shall be responsible for monitoring this tracking system and shall determine when a preponderance of the data indicates that an investigation is necessary." The policy did not contain sufficient information related to how often data would be analyzed to ensure residents were protected from harm and immediate action was taken. m. Under the section titled Evaluation, it stated "All suspected cases of abuse, neglect and misappropriation of resident property will be investigated and reported as required by this procedure and State Law." As identified above, immediate protection to the resident would not be provided, there was no information related to the immediate suspension of alleged staff, and notification of family members and/or legal representatives was not included in the policy. n. Under the section titled Evaluation, it stated "The administrative or nurse charge/manager immediately notifies ...and ...immediately investigates the alleged incident." The policy did not include information on what to do if the alleged staff was the administrative or nurse charge/manager. o. Under the section titled Evaluation, it listed four steps to be utilized to ensure a thorough investigation was conducted. The last two steps were as follows: - "If a staff member is implicated in the incident, the person will be instructed to discuss (sic) situation with the Administrator or the Director of Nursing." As stated, it was not clear who (the implicated staff or the investigator) was to talk with the Administrator or Director of Nursing. - "Continued facility investigation may occur, as needed, over the next 24-48 hours." As stated, completing an investigation was a choice and would not be sufficient to ensure a thorough investigation was completed. Additionally, the policy did not include information related to interviewing the resident(s) involved in the incident. 3. An Incident Investigation, undated, summarized an investigation conducted from 8/13/12 - 8/15/12 regarding an allegation of abuse on Resident #16, during a shower on 8/1/12 by LN #19 and CNA #20. Resident #16 ' s Resident Facesheet, undated, documented a [AGE] year old male whose [DIAGNOSES REDACTED]. a. LN #19 was placed on administrative leave 8/14/12 for protection of the residents, however, CNA #20 was not. When asked during an interview on 2/19/13 from 2:50 - 3:12 p.m., the Administrator stated CNA #20 was not placed on administrative leave because once statements clarifying the allegation were received, the focus was placed on LN #19. b. CNA #3 witnessed the shower on 8/1/12 and reported the incident to LN #4 on 8/12/13. LN #4 then reported the incident to the Administrator on 8/13/13. However, the Incident Investigation did not contain documentation that CNA #3 or LN #4 were retrained on the abuse policy, including immediate protection of residents or immediate reporting. When asked, the Administrator stated during an interview on 2/19/13 from 2:50 - 3:12 p.m. she carried a facility phone 24 hours a day, seven days a week to facilitate immediate reporting. She stated she would check personnel files for documentation of the abuse policy, however, the facility failed to provide any additional documentation. 4. Resident #10 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 10/15/12, coded: * Understood and usually understands * BIMS of 9 indicating moderately impaired cognitive skills for daily decision making * No signs or symptoms of [MEDICAL CONDITION] present * Physical behavioral symptoms directed toward others occurred 1 to 3 days during the 7 day look back period * Verbal behavioral symptoms directed toward others occurred 4 to 6 days during the 7 day look back period * Mood score for depression was zero indicating no signs or symptoms of depression during the 14 day look back period Resident #10's Physician order [REDACTED]. Resident #10 ' s Plan of Care documented the problem, dated 6/18/09, " AIA (unknown). " Interventions included, " ...Provide opportunity for communication/socialization during each contact. " Under the problem, " Ineffective Individual coping, " dated 6/10/09, interventions included, " ...1:1, diversional activities ...validation, redirection. " On 12/13/12, a Social Services Progress Notes entry (untimed), recorded by LSW #1, documented, "Staff have shared info(rmation) about (Resident #10) having had a verbal altercation w/staff (with staff) during dinner last night (12/12/12). He separately threatened physical harm and the staff responded inappropriately, but then walked away. ...Social Services will speak with & remind him of not only the consequences of his action but his responsibility to respect staff and other residents." A second untimed note, recorded on 12/13/12 by LSW #1, documented, "Spoke w/(Administrator's name) who agreed (Resident #10) has now escalated his verbal abuse to physical threats (with) staff. With 2 staff having reacted as shared their inability to cont(inue) working or under this abuse, it may be time to look at transferring (Resident #10) to another facility. ..." During an interview with Employee #20 (E-20), the employee was asked about abuse, in general, in the facility. E-20 said that sometime recently, at least during the last year, E-20 knew about verbal abuse between Resident #10 and a co-worker. E-20 stated, "He (Resident #10) wanted (staff member) to do something. The (staff member) started swearing at (Resident #10) and (the staff member) got fired." The verbal interaction between Resident #10 and a staff member, which took place on 12/12/12 according to LSW #1, was not brought to the attention of the LSW or the Administrative staff until the next day, 12/13/12. The Administrator was notified by LSW #1 of the alleged abuse on 12/13/12. The Bureau of Facility Standards did not record any call to the department's hotline and did not record any faxed report of a completed investigation of the incident of alleged abuse on 12/12/12 as required in Informational Letter #2005-1. The facility failed to report the incident between Resident #10 and a staff member to the Bureau of Facility Standards as required by State law and federal regulations. The facility failed to develop and operationalize policies and procedures that prohibited mistreatment, neglect, and abuse of residents and misappropriation of resident property.

Based on interview and record review, it was determined the facility did not ensure residents were free from unnecessary medications. This was true for 1 of 10 residents (Resident #17) sampled for drug regimen. Resident #17 was harmed when he experienced behavioral changes leading to an increase in one of his [MEDICAL CONDITION] medications ([MEDICATION NAME]), and the addition of 3 more medications ([MEDICATION NAME], and Clonipramine). The facility did not document a thorough investigation of the root causes of the resident's behavioral changes. The unnecessary use of these medications led to adverse reactions of increased lethargy, increased confusion, increased sleeping during the day, and pill rolling. It was ultimately discovered that the facility substantiated an allegation of abuse towards this resident on 8/5/12, and the staff member continued employment at the facility until 9/6/12. Resident #17 successfully tolerated the discontinuation of one of these medications (Clonipramine), a reduction of another ([MEDICATION NAME]), and reduced usage of "as needed" [MEDICATION NAME] after the identified employee was terminated from the facility. Findings included: NOTE: Please see F 225, F 226, and F 490 pertaining to abuse and facility administration. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #17's Quarterly MDS dated [DATE] coded: -BIMS of 8, indicating moderately impaired cognitive skills -No indicators of depression -No behavioral symptoms -Extensive assistance of 1 person for transfers and ADL's -Able to propel his wheelchair independently Resident #17's Quarterly MDS dated [DATE] coded: -BIMS of 10, indicating moderately impaired cognitive skills -No indicators of depression -No behavioral symptoms -Extensive assistance of 1 person required for transfers and most ADL's -Able to propel his wheelchair independently Resident #17's 8/1/12 physician's orders [REDACTED]. -[MEDICATION NAME] 40 mg daily for depression -[MEDICATION NAME] 125 mg twice daily -[MEDICATION NAME] 5 mg twice daily for agitation Resident #17's MD progress note dated 8/15/12 documented, "His dementia is worsening and now having behaviors. These behaviors pertain to an inappropriate fixation on one of our nurses. I have attempted to handle this non-medicinally with re-direction, verbal cuing, etc., however this has been fruitless and we've had to bet the psychiatric staff involved...(RN Manager) is involved and we have already outlined her concerns." Medication changes from August through October 2012 included: 8/15/12: -[MEDICATION NAME] 125 mg twice daily discontinued, [MEDICATION NAME] 250 mg three times daily started. (NOTE: This increased Resident #17's total daily dose from 250 mg per day to 750 mg per day.) -[MEDICATION NAME] discontinued -New order for [MEDICATION NAME] 0.5 mg every 4 hours as needed. -New order for [MEDICATION NAME] 5 mg twice daily for 4 weeks, then increase to 10 mg twice per day 8/29/12: -New order for Clonipramine 25 mg daily for 7 days, then increase to 50 mg daily 10/10/12: -Clonipramine discontinued 11/6/12 -[MEDICATION NAME] 250 mg TID discontinued, with the dosage reduced to 125 mg TID Resident #17's MAR for August 2012 documented [MEDICATION NAME] administered on 8/25/12 at 9:00 AM and 8/27/12 at 8:20 AM. [MEDICATION NAME] was not documented as given in September or October 2012. Resident #17's Nursing Progress Notes (PNs) documented: -8/8/12 at 9:00 AM. "Resident follows LN (LN initials) around and is asked to leave politely but refuses...PRN [MEDICATION NAME] given (with no) noticeable results." -8/12/12 at 2:20 PM. (NOTE: The following entry was made by the staff member later discovered to have been abusing this resident.) "During lunch rsdt (resident) was [MEDICATION NAME] to get this writers attention. When I finally looked rsdt flips this writer off and proceeds to make measurements (with) his hands referring to the size of his penis...Rsdt wheeled from dining room (and) immediately returns...wanting to speak to this LN...rsdt continues to resist leaving dining room...follows this writer. CNA tried to redirect rsdt from this LN, rsdt resisted, cursing and calling CNA names (and) proceeded to ram her (with) his w/c until she moved. This LN asked rsdt to go, he was being inappropriate (and) that he couldn't attack staff. Rsdt finally went to his room." -8/15/12 at 10:50 PM. "Started on increased [MEDICATION NAME] as ordered..." -8/17/12 at 3:30 PM. "(Increased) [MEDICATION NAME] and [MEDICATION NAME] continue...Has been noted to be sleeping more today. Frequently falling asleep sitting the day area in w/c. (At) times mumbling/talking in sleep." -8/25/12 at 1:15 PM. (NOTE: The following entry was made by the staff member later discovered to have been abusing this resident.) "Rsdt cont to follow this LN, wanting to ask '1 question.' When redirected activities explained that LN was busy...rsdt back on north hallway. When CNA attempting to re-direct rsdt, rsdt threatening to stand up (and) hurt CNA (and) threw a cup of (water) onto CNA..." -8/25/12 at 3:35 PM. "RN reports resident aggressive (with) agitation (and) anger (with) swinging (at) CNA (and) also cursing...continues to be aggressive toward [MEDICATION NAME] given X 1 (and) resident fell asleep for approx 2 hrs." (NOTE: The RN referred to in the above entry is the staff member later discovered to have abused this resident.) -8/27/12 at 7:00 AM. "...Staring at nurse or looking in at her. (LN name) states she's been talking to him (and) requested he be wheeled away. Attempted to move or wheel rsdt away (and) rsdt refused to put feet down...PRN [MEDICATION NAME] given to try to alleviate situation." (NOTE: On both occasions Resident #17 received [MEDICATION NAME], he was either in the presence of the staff member later found to have abused him, or had been documented to have been in her presence, with agitation present, within the past 2 1/2 hours.) Resident #17's PNs continued: -9/1/12 at 11:00 PM. "(No) behavior problems..." -9/2/12 at 3:30 PM. "Happy (and) pleasant..." -9/21/12 at 2:30 PM. "Does sleep often throughout the day. (Increased) STML (short-term memory loss) this AM..." -10/8/12 at 2:40 PM. "Res(ident) with (increased) lethargy this shift. Res sleeping in wc with hands curling in (at) the wrists...res cogwheeling. Res (with increased) confusion grasping (at) things (and) pill rolling while sleeping..." -10/9/12 at 2:15 PM. "Res slept 5 (hours) this shift. While sleeping res reaching out (with) hands 'pill rolling' fingers, posturing hands...slightly confused when woke..." -10/10/12, time illegible. "N.O. (new order) d/c [MEDICATION NAME]." -10/10/12 at 1:50 PM. "Held [MEDICATION NAME] X 2 (twice) this shift. Res slept 2 (hours) this shift..." On 2/14/13 at 12:40 PM, the surveyor asked to see facility abuse investigation files as part of the standard abuse task. LSW #1 provided an investigation which documented LN #19 abused Resident #17, with an onset date of 8/5/12. LN #19 continued employment at the facility until 9/6/12, with her last date of contact with Resident #17 as 8/27/12. LSW#1 was asked for any additional information regarding the reporting and investigation of this information, including a facility incident report. LSW #1 stated there was no additional information beyond what was already provided. On 2/15/13 at 9:07 AM, LN #10 was interviewed regarding Resident #17's medication changes. LN#10 stated the facility had requested the physician order [REDACTED]. On 2/15/13 at 1:15 PM, Resident #17's physician was interviewed regarding medication changes for this resident in light of the abuse event. The MD stated the medications were added per request of facility nursing staff, most likely LN #10 or the RN Manager. The MD stated he was informed that Resident #17 had "sexual behaviors" towards a LN #19, but had not been informed of the LN's behaviors towards the resident. The MD stated he had been informed LN #19 and Resident #17 would be kept separate form one another. The MD stated he would normally be informed of such things through a facility incident report, although he did not see an indictment report of abuse in this case. The MD reported the resident had no other behaviors contributing to the increase or addition of medications. The MD stated Resident #17 has not had any behavioral symptoms since the time LN #19 left the facility. On 2/19/13 at 2:10 PM, the Administrator and DON were informed of these findings. The facility offered no further information.