Every finding on record at Ironwood Rehabilitation and Care Center

Based on record review, SOM Appendix PP, and staff interview it was determined the facility failed to provide quality care for residents. This was true for 4 of 20 (#2, #4, #8, and #51) whose records were reviewed. This deficient practice created the potential for harm when Resident #2's bowel protocol was not followed, when staff did not follow physician's orders for Resident #4 and #8, and when Resident #51 did not have a skin assessments completed. Findings include:SOM Appendix PP updated 4/25/25 documented quality of care is a fundamental principle applying to all treatment and care provided to facility residents where the facility must ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. 1. Resident #51 was readmitted to the facility on [DATE], with multiple diagnoses including obesity, Parkinson's disease, cognitive communication deficit, bipolar disorder, and borderline personality disorder. A physician's order dated 4/15/26, documented Resident #51 should receive weekly skin assessments every evening shift on Tuesday starting 4/21/26. A Skin assessment dated [DATE], documented Resident #51 had no skin issues. No skin assessment was completed on 4/28/26. A nursing progress note dated 4/29/26, documented Resident #51 did not have any change to his skin. On 4/29/26 at 10:35 PM, Resident #51 and his representative complained about a red rash that was spreading from under the left lower arm, down into the abdominal area and slowly going down into the groin area. Resident #51's representative stated he had been putting cream Nystatin powder on the rash to calm it down as the facility had not done anything about it even after multiple requests to care for it over the past three weeks. On 4/30/26 at 3:30 PM, Surveyor, with Resident #51's permission and his representative present, CNA #2, SA observed a rash under Resident #51's left arm, going down into the panna/apron (lower abdomen skinfold) area of the abdomen, around towards his back, and down into his groin area. The area under his arm and flank skin fold were bright red, shiny and appeared moist. Resident #51 stated the areas itched and were painful. A review of Resident #51's record did not document Nystatin was a current medication. On 4/30/36 at 4:00 PM, the DON and RN #1 stated there should have been a weekly skin assessment on 4/28/26. They also verified residents are not provided with medication without a physician's order. 2. Resident #4 was readmitted to the facility on [DATE], with multiple diagnoses including dementia, cognitive communication deficit, PTSD, and depression. On 4/28/26 at 11:58 AM, Resident #4 ended the surveyor interview stating she was tired and needed to rest before lunch. She stated she is usually sleepy and needs to rest before activities. Resident #4's care plan, initiated on 5/30/25, directed staff to observe for signs and symptoms of mood change, changes in normal behavior, social isolation, and/or fatigue related to antidepressant medication use and to report to physicians any signs or symptoms of fatigue related to anemia. Physician's orders included the following: -Monitor antidepressant medication side effects using the following scale: 0=none; 1=sedation; 2=drowsiness; 3=headache; 4=decreased appetite; 5=less common s/e; 6=dry mouth; 7=blurred vision; and 8=urinary retention every shift, dated 1/12/26. -Monitor episodes of behaviors every shift, dated 1/12/26. - Sertraline (anti-depressant) HCL tablet 100 mg, give 100 mg by mouth in the morning for depression, dated 2/5/26. A review of Resident #4's MAR and TAR documented the following dates of behavior monitoring were not recorded as ordered: - January 2026: 15 of 50 opportunities - February 2026: 9 of 56 opportunities - March 2026: 16 of 62 opportunities - April 2026: 3 of 60 opportunities A review of Resident #4's MAR and TAR documented the following dates Sertraline was not given: - January 2026: 14 of 50 opportunities - February 2026: 4 of 56 opportunities - March 2026: 13 of 62 opportunities - April 2026: 2 of 60 opportunities On 4/30/26 at 2:44 PM, the CRN stated facility staff should have been monitoring and documenting the behaviors and medication administration at every shift. 3. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including cognitive communication deficit, bipolar disorder, dementia, and depression. Resident #8's care plan, initiated on 11/26/25, directed staff to observe for signs and symptoms of mood change, changes in normal behavior, social isolation, and/or fatigue related to antidepressant and antipsychotic medication use and to report to physicians any signs or symptoms. Physician's orders included the following: -Monitor antipsychotic medication side effects using the following scale: 0=none, 1=drowsiness, 2=dry mouth, 3=blurred vision, 4=constipation, 5=edema, 6=extra pyramidal symptoms, 7=urinary retention, 8=stiff or tight muscles, 9=restlessness, and 10=tardive dyskinesia every shift, dated 12/12/25. -Monitor antidepressant medication side effects using the following scale: 0=none; 1=sedation; 2=drowsiness; 3=headache; 4=decreased appetite; 5=less common s/e; 6=dry mouth; 7=blurred vision; and 8=urinary retention every shift, dated 4/27/26. -Monitor episodes of behaviors every shift, dated 4/10/26. Physician's orders included the following: - Aripiprazole (antidepressant) oral tablet 10 mg, give 1 tablet by mouth at bedtime for bipolar disorder, dated 4/2/26. - Trazadone (antidepressant) HCL oral tablet 50 mg, give 25 mg by mouth at bedtime for insomnia, dated 12/26/25. A review of Resident #4's MAR and TAR documented the following dates of behavior monitoring were not recorded as ordered: - January 2026: 14 of 62 opportunities - February 2026: 4 of 56 opportunities - March 2026: 13 of 62 opportunities - April 2026: 1 of 60 opportunities On 4/30/26 at 2:44 PM, the CRN stated facility staff should have been monitoring and documenting the behaviors and medication administration at every shift. 4. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses, including Parkinson's Disease without Dyskinesia (a movement disorder characterized by involuntary, erratic, and sometimes painful body movements) and diabetes. A physician's order documented Resident #2 was to receive the following bowel medications: -Polyethylene Glycol (laxative) 3350 powder give one scoop by mouth in the morning for constipation. Dissolve in 6-8 oz of liquid -Dulcolax 10 mg tablet, one tablet by mouth every 24 hours as needed for no bowel movement after three days, ordered 9/23/25. -MOM (Milk of Magnesia - laxative), give 30 cc every 24 hours as needed for bowel care if no bowel movement after three days, ordered 9/23/25. -Dulcolax Suppository (Bisacodyl) insert 10 mg rectally every 24 hours as needed for bowel care if no results from MOM, ordered 9/23/25. -Fleet enema insert one unit rectally every 24 hours as needed for bowel care if no results from Dulcolax, ordered 9/23/25. A review of Resident #2's Bowel Record documented that she did not have bowel movement from 4/6/26 through 4/10/26 (5 days). A review of Resident #2's MAR did not document she receive her bowel medication when she did not have a bowel movement for three days. On 5/1/26 at 11:07 AM, the IP and CRN reviewed Resident #2's bowel record. The CRN stated Resident #2 did not have a bowel movement from 4/6/26 through 4/10/26 (5 days). The CRN stated they will review Resident #2's record and will get back to the surveyor. On 5/1/26 at 11:32 AM, the CRN stated Resident #2 did not receive her bowel medications as needed.

Based on observation, policy review, resident interview, and staff interview, it was determined the facility failed to ensure residents were provided a safe, comfortable, and homelike environment. This was true for 2 of 2 residents (#13 and #30) whose rooms were observed with wear or damage and for residents living in 2 of 3 Halls (South and East Halls) who experienced uneven flooring. These deficient practices created the potential for the residents to experience accidents and psychosocial harm due to the conditions of the rooms and uneven flooring. Findings include:1. a. Resident #13 was admitted to the facility on [DATE] with multiple diagnoses including, atrial fibrillation (irregular heartbeat), and dementia (a progressive irreversible syndrome causing decline in memory, thinking, and daily functioning). On 4/27/26 at 12:48 PM, observed Resident #13's room, which had at least 7 holes in the wall over the bed and scattered areas of missing paint on the same wall. On the wall edge next to bed, a large area of chipped off drywall from the baseboard and up measuring approximately 36 inches, and missing paint. b. Resident #30 was admitted to the facility on [DATE] with multiple diagnoses including dementia, and stroke (when blood flow to part of the brain is interrupted or reduced, causing brain tissue to die due to lack of oxygen). On 4/27/26 at 1:12 PM, observed Resident #30's room with multiple areas of paint missing on walls by the window and the East wall. Large water stains were observed on the ceiling above the sink. On 4/30/26 at 9:49 AM, the Maintenance Supervisor confirmed the holes, missing paint and water stain in the residents rooms and stated, we have a lot of issues with the holes in residents' walls and need for paint. He stated he did not currently have a plan for the repairs and paint, but will make it a priority to be fixed. 2. On 4/27/26 at 10:45 AM, multiple divots were observed throughout the hallways on the East and South Halls. Drainage covers were observed to be discolored and flooring was chipped and cracked off around the drain covers, creating uneven divots. Multiple chipped flooring divots partially filled with shellac were observed throughout the floor near the nurses' station and in both East and South Hallways. On 4/27/26 at 3:38 PM, Resident #5 stated he had seen wheelchairs get stuck in the rut and not be able to move throughout the hallways. On 4/30/26 at 9:20 AM, the Maintenance Director confirmed the flooring was not flush with the drainage covers, and there were multiple divots throughout the East and South hallways.

Based on observation and staff interview, it was determined the facility failed to ensure residents were treated with dignity and respect. This was true for 1 of 3 residents (Resident #50) observed during cares. This deficient practice created the potential for psychosocial harm if Resident #50 experienced embarrassment or lack of self-esteem. Findings include: Resident #50 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses, including Down Syndrome and chronic respiratory failure with hypoxia (low levels of oxygen in the blood).On 4/30/26 at 1:23 PM, RN #2 assisted by CNA #1 performed wound care to Resident #50's bottom. RN #1 was also observed to clean Resident #50's penis. Resident #50's window curtain was not drawn to provide privacy. He was visible to the outside while receiving wound care.On 4/30/26 at 1:42 PM, RN #2 stated he did not notice Resident #50's curtain was not drawn while he was providing wound care. RN #2 stated the curtain should have been drawn to provide privacy to Resident #50.

Based on observation, record review, and staff interviews, it was determined the facility failed to provide self-administration of medication assessments. This was true for 1 of 3 residents (Resident #5) whose record was reviewed for self-administration of medications. This deficient practice created the potential for harm if Resident #5 took too much or too little of his inhaled medication, or suffered adverse effects, such as oral thrush, due to lack of assessment. Findings include:Resident #5 was readmitted to the facility on [DATE], with multiple diagnoses including quadriplegia (a medical condition involving paralysis of all four limbs and the torso, often caused by spinal cord injury, stroke, or disease), muscle weakness, stage 4 pressure ulcer of right buttock, anxiety, depression, emphysema (a chronic, progressive lung disease that makes it hard to breathe by destroying the delicate air sacs (alveoli) in the lungs), and sleep apnea (serious disorder where breathing repeatedly stops and starts during sleep, preventing restful, quality sleep).On 4/27/26 at 3:20 PM, it was observed Resident #5 had an inhaler on his bedside table.A physician's order dated 12/3/25 documented Proventil HFA (albuterol sulfate) Inhalation Aerosol Solution 108 mcg/act, 2 puffs inhale orally every 4 hours as needed for [shortness of breath], rinse mouth after use.A review of Resident #51's record did not document a self-administration of medication assessment.On 4/30/26 at 4:05 PM, the DON stated Resident #5 should not be self-administering medication without an assessment, and there should have been one.Cross Reference F761

Based on review of records and staff interviews it was determined the facility failed to ensure a bed-hold notice was provided to a resident and/or their representatives. This was true for 1 of 3 resident (Resident #50) whose records was reviewed. This failure created the potential for psychosocial distress if Resident #50 could not return to the facility following hospitalization. Findings include:The State Operation Manual Appendix PP, issued 7/23/25, documented At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy.Resident #50 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses, including Down Syndrome and chronic respiratory failure with hypoxia (low levels of oxygen in the blood).A Nursing Notes dated 3/30/26, documented Resident #50 was noted to have involuntary movement. Resident #50 had extreme labored breathing and oxygen was administered. EMS was called and Resident #50 was transferred to the hospital.A review of Resident #50's record did not document a bed-hold notice was provided to his representative when he was transferred to the hospital.On 5/1/26 at 1:23 PM, RN #1 stated she was unable to find documentation a bed-hold notice was provided to Resident #50 and/or his representatives when he was sent to the hospital.

Based on staff interview and record review, the facility failed to develop and implement residents' comprehensive person-centered care plan. This was true for 1 of 20 residents (Resident #6) whose care plan was reviewed. This deficient practice placed Resident #6 at risk for their health and wellbeing with negative outcomes if services were not provided or provided incorrectly. Findings include: The facility's policy titled, Comprehensive Person-Centered Care Planning stated, 'It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. Resident #6 was admitted to the facility on [DATE], and readmitted [DATE], with multiple diagnoses including fracture of left tibia (break in the shin bone), stroke (the death of brain tissue caused by a sudden lack of oxygen due to obstructed blood flow), unsteadiness on feet, need for assistance with personal care, and muscle weakness (generalized). A physician's order dated 4/9/26 documented, OK to have 5 oz of wine daily prn every 24 hours as needed. Resident #6's comprehensive person-centered care had not documented the use of wine as written in the physician order.On 4/30/26 at 4:30 PM, the DON stated Resident #6 did not have wine use care planned, and she confirmed it should have been.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure staff administered and disposed of medications according to professional standards. This was true for 1 of 4 residents (Resident #79) observed during medication administration, and 1 of 6 residents (Resident #11) whose medication regimen were reviewed. These failures created the risk for harm when Resident #79's medication was not disposed of appropriately and when the nurse did not follow the physician's order for two medications, and a risk for harm to Resident #11 when two of their medication orders were written to administer by the wrong route. Findings include: -The National Library of Medicine web page titled Nursing Rights of Medication Administration, accessed 5/5/26, documented the five traditional rights for medication administration are, Right Patient, Right Drug, Right Route, Right Time, Right Dose. -PharmcareUSA - Medication Disposal in Long Term Care, accessed 5/5/26, documented, When medications are not disposed of properly, they may increase the risk of diversion, accidental exposure, or unintended use. Improper handling can also create avoidable safety concerns for residents, staff, and visitors. 1. Resident #79 was admitted to the facility on [DATE] with multiple diagnoses including multiple fractures to their right ribs, chronic obstructive pulmonary disease (COPD is a disease that causes airflow blockage and breathing related problems), and hypertension (high blood pressure). a. Resident #79's record documented a physician order: Cozaar Tablet 25 MG (Losartan Potassium) Give 1 tablet by mouth in the morning for hypertension, hold for [systolic blood pressure less than] 100, ordered 4/29/26. On 4/30/26 at 9:26 AM, LPN #1 was observed measuring Resident #79's blood pressure, with a result of systolic/diastolic of 108/70. LPN #1 was observed explaining to Resident #79 that their blood pressure was too low to administer the blood pressure medication. On 4/30/26 at 10:10 AM, the DON and RN #1 stated LPN #1 did not follow the physician's order and held Resident #79's losartan in error. b. On 4/30/26 at 9:30 AM, LPN #1 was observed holding a medication cup with one tablet in it over the garbage can in Resident #79's room, turning the cup over, the tablet fell into the garbage can, then she dropped the medication cup into the garbage can. On 4/30/26 at 9:46 AM, LPN #1 stated when prepared medications are not administered they are disposed of in a pharmacy provided box for medication returns or a Drug Buster (a bottle with chemicals to make the medication useless and non-retrievable). LPN #1 stated, she should not have thrown a tablet away in the garbage can in the resident's room. c. Resident #79's record documented a physician's' order for Breyna Inhalation Aerosol 160-4.5 mcg/act (Budesonide Formoterol Fumarate Dihydrate) 2 puff inhale orally two times a day for [shortness of breath] rinse mouth after use, ordered 4/29/26.On 4/30/26 at 9:38 AM, LPN #1 was observed assisting Resident #79 to use his Breyna Inhaler. She placed the mouthpiece in his mouth and instructed him to take a breath when she pressed the inhaler to dispense the dose, she repeated the administration as ordered. LPN #1 then gathered her supplies and left Resident #79's room. LPN #1 was not observed asking Resident #79 to rinse his mouth after the use of the inhaler or providing education to why rinsing the mouth after the use of an inhaler was recommended. On 4/30/26 at 4:53 PM, the DON stated LPN #1 should always follow the physician's' order thoroughly and should have instructed Resident #79 to rinse his mouth after using an inhaler. 2. Resident #11 was admitted to the facility on [DATE] with multiple diagnoses including emphysema, muscle weakness, a need for assistance with personal care, and had a colostomy (a surgical opening from the intestine through the abdominal wall to bypass the rectum). Resident #11's record documented the following physicians orders:-Dulcolax Suppository (Bisacodyl) Insert 10 mg rectally every 24 hours as needed for bowel care if no results from [milk of magnesia], ordered 2/3/26 -Fleet Enema, Insert 1 unit rectally every 24 hours as needed for bowel care if no results from [suppository], ordered 2/3/26 On 4/30/26 at 4:56 PM, RN #1 stated Resident #11 had a colostomy and could not use any medications rectally and the route on the physicians' order is wrong for the bisacodyl suppository and fleet enema.

Based on review of records and interviews, it was determined the facility failed to ensure residents who were dependent on staff for activities of daily living (ADLs) received bath/shower assistance. This was true for 1 of 1 resident (Resident #20) whose ADL record was reviewed. This deficient practice created the potential for Resident #20 to experience diminished self-worth, embarrassment, and an increased risk for developing skin conditions. Findings include: Resident #20 was admitted to the facility on [DATE] with multiple diagnoses, including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a stroke, diabetes, dysphagia (difficulty swallowing), and dysarthria (slurred, slow, or difficult to understand speech).An MDS Comprehensive assessment dated [DATE], documented Resident #20 was cognitively intact.On 4/29/26 at 3:44 PM, Resident #20 stated she was to be showered two times a week every Sunday and Thursday, but she only receives one shower a week. Resident #20 stated she did not refuse when she was offered a shower/bath.An ADL care plan initiated 5/29/25, documented Resident #20 required help in part of bathing activity. The care plan documented Resident #20 preferred to have two showers weekly in the morning.Resident #20's Bathing Flowsheets documented she received a shower on 4/2/26 and received her next shower on 4/16/26, 14 days later.Review of nursing notes did not document Resident #20 refused showers.On 4/30/26 at 2:35 PM, Resident #20's shower's flowsheet was reviewed with the DON. The DON confirmed Resident #20 did not have a shower on 4/5/26, 4/9/26 and 4/12/26. The DON also reviewed the PRN shower flowsheet and stated there was no PRN shower provided to Resident #20.

Based on observation, SOM Appendix PP, and resident and staff interview, it was determined the facility failed to assess the safety of a resident electing to smoke. This was true for 1 of 3 residents (Resident #80) whose record was reviewed for safe smoking assessments. This deficient practice created the potential for harm if a resident was not appropriately assessed for safety related to smoking. Findings include:SOM Appendix PP, updated 7/23/25, documented assessment of the resident's capabilities and deficits determines if supervision while smoking is necessary.Resident #80 was admitted to the facility on [DATE], and re-admitted on [DATE], with multiple diagnoses including COPD, chronic bronchitis, nicotine dependence, depression, anxiety, and mood disorder.On 4/27/26 at 3:51 PM, Resident #80 asked the surveyor to unlock the nursing cart so she could get her cigarettes.On 4/27/26 at 5:06 PM, the facility identified Resident #80 as one of the facility's resident's who chose to smoke. A Smoking Assessment, dated 4/23/26, documented Resident #80 was a non-smoker.Resident #80's care plan, dated 4/27/26, documented Resident #80 was safe to smoke independently.There was no additional smoking assessment found in Resident #80's record.On 4/30/26, the DON and RN #1, stated there were no additional smoking assessments after 4/23/26, and there should have been one after her re-admission on [DATE].

Based on observation, record review, and resident and staff interview, it was determined the facility failed to provide respiratory care as ordered by the physician. This was true for 1 of 3 residents (Resident #5) whose record was reviewed for oxygen therapy. This deficient practice created the potential for harm if resident's oxygen therapy did not follow physician's orders. Findings include: Resident #5 was readmitted to the facility on [DATE], with multiple diagnoses including quadriplegia, muscle weakness, stage 4 pressure ulcer of right buttock, anxiety, depression, emphysema, and sleep apnea.a. A physician's order dated 12/3/25 documented Resident #5 to receive oxygen at 0-4 LPM, as needed for SOB related to respiratory failure with hypoxia.On 4/27/26 at 3:38 PM, Resident #5's nasal cannula was observed hanging over the oxygen condenser without any covering on it.On 4/27/26 at 3:40 PM, Resident #5 stated he had used his nasal cannula the night before.On 4/28/26 at 9:43 AM, LPN #2 was asked to verify if the nasal cannula was properly stored. LPN #2 stated, No, the nasal cannula should be stored in clear bag on the oxygen condenser.The facility was unable to provide an Oxygen Equipment or Respiratory Therapy policy relating to the proper storage of a nasal cannula. On 5/1/26 at 9:01 AM, the CRN stated the facility did not have any Oxygen Therapy policies and staff are instructed to follow physician's orders related to the care and treatment of any oxygen services. When asked to clarify if a physician's orders were needed to store the nasal cannula in a separate bag, the CRN stated, Yes.b. A physician's order dated 12/3/25 documented to change tubing, clean filter and change oxygen water bottle every night shift every Sunday.On 4/27/26 at 3:38 PM, it was observed the oxygen tubing for Resident #5 did not have a date of change on the tubing.On 4/28/26 at 9:42 AM, LPN #2 confirmed there was no date located on Resident #5's oxygen tubing.A review of the MAR for April 2026 documented Resident #5 received an oxygen tubing change on 4/26/26.On 4/28/26 at 9:45 AM, LPN #2 stated the tubing should have been dated when it was changed out, and it was not.

Based on observation, record review and staff interview, it was determined the facility failed to ensure medications were stored securely. This was true for 1 of 3 medication carts observed (North Hall Med Cart). This failure created the potential for harm related to unmonitored use of medications. Findings include: On 4/30/26 at 8:59 AM, the medication cart on the North Hall was observed to be unlocked and unattended. On 4/30/26 at 9:03 AM, LPN #1 returned to the medication cart. LPN #1 stated the cart was locked and attempted to demonstrate by pulling on a drawer handle, the drawer opened. LPN #1 stated the cart locked on a timer and she thought the cart was locked when she stepped away. LPN #1 stated she did not know how long the timer on the cart took to lock when left unattended and added she should have double checked it. On 4/30/26 at 9:59 AM, the CRN stated medication carts must be locked when the staff leave it unattended.

Based on record review and staff interview, it was determined, the facility failed to ensure a residents medical record was complete and accurately documented. This was true for 1 of 6 residents (Resident #11) whose medication regimen were reviewed. This failure created the potential for poor continuity of care and medication error when Resident #11's medication administration record (MAR) did not record their medications were not administered due to a hospitalization. Findings include: Resident #11 was admitted to the facility on [DATE] with multiple diagnoses including emphysema, muscle weakness, and a need for assistance with personal care. Resident #11's MAR documented, on 4/16/26, their midday and bedtime medications were not administered and on 4/17/26, their early morning medications were not administered. Resident #11's MAR did not include documentation of a code recording why the medications were not administered and the spaces for documentation were left blank. On 4/30/26 at 4:52 PM, the DON stated Resident #11 was at the hospital on 4/16 and 4/17 and the nurses administering medications should have recorded that on the MAR. The DON added, there should never be blanks on the MAR.

Based on observation, review of CDC guidance, and interviews, it was determined the facility failed to ensure an infection control program was implemented. This was true for 1 of 1 resident (Resident #37) whose intravenous site was observed, and 1 of 1 staff (RN #2) who was observed while providing wound care to Resident #50. This deficient practice created the potential for Resident #37 to develop an infection to his IV site and the spread of infection due to cross contamination when RN #2 did not perform hand hygiene when changing gloves. Findings include: The CDC webpage titled Clinical Safety: Hand Hygiene for Healthcare Workers was accessed on 5/5/26, documented gloves were not a substitute for hand hygiene. The CDC recommended the following:-Perform hand hygiene before donning gloves and touching the patient or the patient's surroundings.-Always clean your hands after removing gloves.The facility's Infection Control policy revised 1/26, documented hand hygiene should be performed before donning sterile gloves and after removing gloves.1. Resident #50 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses, including Down Syndrome and chronic respiratory failure with hypoxia (low levels of oxygen in the blood).A care plan revised 4/17/26 documented Resident #50 had moisture associated skin disorder to his buttocks and staff were directed to administer treatments as ordered.On 4/30/26 at 1:23 PM, RN #2 assisted by CNA #1 performed wound care to Resident #50. RN #2 wiped Resident #50's bottom and applied a new incontinence brief. RN #2 removed his gloves and put on new pair of gloves without performing hand hygiene. RN #2 then was observed to put on another pair of gloves to his already gloved hands. RN #2 proceeded to apply the Triamcinolone cream to Resident #50's bottom, removed the first pair gloves to expose another pair of gloves and then cleaned Resident #50's penis. RN #2 then applied Triamcinolone cream to Resident #50's penis, removed his gloves and put on a new gloves without performing hand hygiene. RN #2 then secure Resident #50's incontinence brief.On 4/30/26 at 1:42 PM, RN #2 stated he put on two gloves on both hands, applied the Triamcinolone cream to Resident #50's bottom and then cleaned his penis. RN #2 stated he then removed the gloves and proceeded to apply the Triamcinolone cream to his penis with his gloved hand. RN #2 stated he did not perform hand hygiene when he changed his gloves.On 5/1/26 at 9:30 AM, the IP stated wearing double gloves was not allowed in the facility and hand hygiene should be performed before and after donning gloves.2. Resident #37 was admitted to the facility on [DATE] and readmitted [DATE] with multiple diagnoses including, hemiplegia (paralysis on side of the body) and hemiparesis (weakness on one side of the body) following a stroke, dysphagia (difficulty swallowing) and muscle weakness.A Quarterly MDS assessment dated [DATE], documented Resident #37 was cognitively intact.The CDC MMWR (Morbidity and Mortality Weekly Report) webpage accessed on 5/6/26, stated Replace gauze dressing every 2 days and transparent dressing every 7 days on short term catheters. Replace the dressing when the catheter is replaced, or when the dressing becomes damp, loosened, or soiled, or when inspection of the site is necessary.On 4/27/26 at 3:13 PM, Resident #37 was awake in bed. He was observed to have an intravenous (IV) access site to his right wrist which was covered with a transparent dressing. A black looking material was noted on top of the insertion site. Resident #37 stated it was dried blood and had been there for a while. Resident #37 stated the IV was used for his antibiotic, and it was completed few days ago. When asked if the IV site was hurting, Resident #37 stated No.A review of Resident #37's April 2026 MAR, documented he received 2 grams ceftriaxone sodium solution reconstituted intravenously once a day for infection/appendicitis, ordered for 11 days which was completed on 4/24/26.On 4/27/26 at 3:20 PM, RN #3 checked Resident #37's IV site and asked him if it was hurting, Resident #37 stated it was not hurting.On 4/27/26 at 3:29 PM, the IP stated they received an order to remove Resident #37's IV access site. The IP and RN #3 donned gown and gloves and entered Resident #37's room to remove his IV tubing from his right wrist. RN #3 was asked to measure the dried blood, and it was 5 cm long by 2 cm wide. RN #3 then gently lifted the edges of the transparent dressing and removed it slowly. As RN #3 was lifting the clear dressing, the dried blood was noted to stick to the clear dressing. A wet and gel like dark brown looking material (blood) was observed above the insertion site. RN #3 then pull the catheter and cleaned the site.On 4/27/26 at 3:36 PM, the IP stated if the dressing on the IV site was soiled, it must be changed. When asked if Resident #37's dressing to his IV site was soiled, the IP stated Yes, if it's soiled with blood, then it has to be changed.On 4/27/26 at 4:12 PM, DON #2 stated the expectation was for the nurse to change the dressing if blood was noted on the IV insertion site.

Based on record review and staff interview, it was determined the facility failed to ensure residents were provided with the pneumococcal vaccine when requested. This was true for 1 of 5 residents (Resident #6) whose medical records were reviewed for pneumococcal immunization. This failure created the potential for Resident #6 to have an increased risk of pneumococcal pneumonia (a serious bacterial lung infection) and the potential for severe illness or death. Findings include: The facility's policy, titled Immunizations-Residents, dated 1/26 documented, It is the policy of this facility to offer and administer influenza, pneumococcal, and COVID-19 immunization to eligible residents after providing education on the risks and potential side effects of the vaccine(s) and obtaining consent. Resident #6 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including fracture of left tibia, stroke, unsteadiness on feet, need for assistance with personal care, and muscle weakness (generalized). A review of Resident #6's medical record showed on 9/27/25, she consented to receive the pneumococcal vaccine as per CDC guidance. The record did not include documentation the vaccine had been given. On 5/1/26 at 9:30 AM, the IP stated she misunderstood the information and thought Resident #6 was up to date on her pneumococcal vaccine and was mistaken. The IP stated she will offer the vaccine to Resident #6 when she returns to the facility.

Based on review of medical records, the State Survey Agency's Long-Term Care Reporting Portal, and staff interviews, it was determined the facility failed to ensure residents' rights were protected to be free from abuse and neglect. This was true for 2 of 9 residents (#69 and #72) reviewed for abuse and neglect. This failure placed all residents at risk of ongoing abuse and neglect, and potential physical and psychosocial harm. Findings include: 1. Resident #72 was admitted to the facility on [DATE], with multiple diagnoses including osteoporosis with fracture to right humerus, right pelvis, and vertebra(e), hypertension, and bilateral hearing loss. Resident #72 passed away on 5/1/24. A facility reported incident investigation, initiated 4/12/24, documented Resident #72 reported to the facility that, on 4/12/24, PT #1 came to her room to take her to a therapy session. Resident #72 declined since she was preparing to move to another room. PT #1 responded by throwing a soiled bed pan and a urinal at Resident #72 resulting in urine splashing onto her arm. The facility's investigation documented: - Resident #72 was deaf but could detect pitch and required a white board for communication. She was tearful as she recalled the incident. She stated, during the incident, PT #1 did not use the white board to communicate with her and was yelling at her. - PT #1 stated she used a whiteboard, mouthing, and gestures to communicate with Resident #72, and that Resident #72 was not listening to her explanations. - NAIT #1, who was present during the incident, stated PT #1 threw the soiled bed pan onto Resident #72 and did not use a white board to communicate with her. NAIT #1 stated, because of the incident, she had to clean feces and urine off Resident #72. The investigation documented a previous grievance, dated 3/16/23, included allegations that PT #1 had been rude to another resident who she left in a hallway without his walker. The facility investigation concluded that PT #1 did throw a bed pan and urinal at Resident #72 causing the contents to splash onto her. On 9/26/24 at 12:25 PM, the DON, Interim DON, and Administrator were interviewed together. When asked what corrective actions were taken as a result of the 4/12/24 incident involving Resident #72 and PT #1, the Interim DON stated PT #1 was suspended during the investigation, then terminated from employment at the facility on 4/17/24. On 4/26/24, the State Licensure Board was notified, by the facility, of the abuse allegations and investigative findings related to PT #1's involvement in the incident. The Interim DON stated the investigation determined that burnout may have been a factor in PT #1's behavior, therefore, all staff were educated on abuse/neglect and identifying burnout, which was completed on 4/30/24. Additionally, the staff were offered counseling services for burnout. 48401 2. Resident #69 was admitted to the facility on [DATE], for care after a spinal surgery and had multiple diagnoses including age-related osteoporosis with current pathological fracture and history of urinary tract infections. An Admission MDS, dated [DATE], documented Resident #69 was assessed to be cognitively intact. Resident #69's care plan, dated 4/12/24, documented she required extensive assistance with personal hygiene A facility reported incident investigation, initiated on 4/15/24, documented Resident #69 used her call light to ask for assistance being changed after bowel movement incontinence. She reported NAIT #1 responded to her call light and stated she needed to get a second staff to help her, and then did not return. Resident #69 stated she used her call light to request help to be changed 3-4 times in which NAIT #1 responded to her light the same way each time and she did not receive help getting changed. RN #2's witness statement, dated 4/15/24 at 11:58 PM, documented Resident #69 asked to be helped with incontinence care at approximately 6:30 PM when she was administering her medications. RN #2 stated she asked NAIT #1 to assist Resident #69 with incontinence care and NAIT #1 agreed. An hour later, RN #2 asked NAIT #1 if Resident #69 had been helped with incontinence care. NAIT #1 responded, yes and added she had informed CNA #2 that Resident #69 had been helped with incontinence care. At 11:00 PM, CNA #2 approached RN #2 and stated Resident #69 was reporting NAIT #1 had repeatedly turned off her call light saying she was going to get help but did not return or complete incontinence care. The facility's investigation concluded NAIT #1 had neglected to help Resident #69 with incontinence care. On 9/26/24 at 11:18 AM, the Administrator stated she was not the administrator at the time of these events and, it was unfortunate because the staff were provided so much training. The Administrator stated it was appropriate for the facility to substantiate this allegation of neglect. The facility took the following actions after the allegation: - NAIT #1 was suspended immediately during the investigation. - Resident #69 was interviewed and showed no signs of psychosocial harm from the incident. - Nine other residents were interviewed about their care at the facility and none of those residents raised concerns regarding neglect or feeling unsafe. - The allegation and investigation were submitted to the State Survey Agency's Long-Term Care Reporting Portal in compliance with regulations. - Following the substantiation of the allegation, the facility terminated the employment of NAIT #1 on 4/19/24. - On 4/30/24, the facility provided retraining to all nursing staff regarding abuse, neglect, and how to manage burnout. These findings represent past noncompliance with this regulatory requirement. There was sufficient evidence the facility corrected the noncompliance as of 4/30/24 and there were no other occurrences of alleged abuse or neglect. At the time of this survey, the facility was in substantial compliance for this regulatory requirement and, therefore, does not require a plan of correction.

Based on documentation and staff interview, it was determined that the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of food and nutrition services, including resident assessments, individual plans of care, and the number, acuity, and diagnoses of the facility's resident population. These deficiencies had the potential to affect all residents requiring medical nutrition therapy, nutritional assessments, and appropriate supplementation and dietary interventions. Findings include: The State Operations Manual, Appendix PP, revised 8/8/24, documented, if a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services. The director of food and nutrition services must at a minimum meet one of the following qualifications: - A certified dietary manager. - A certified food service manager, or - Has similar national certification for food service management and safety from a national certifying body; or - Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or - Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, forborne illness, sanitation procedures, and food purchasing/receiving. On 9/22/24, the facility provided documentation they employed a part-time dietitian. On 9/24/24 at 3:15 PM, the DM stated that she had completed food services manager training on 7/17/24, but had not yet taken the certification exam. She had been the DM for the facility for the last five years. On 9/26/24 at 12:34 PM, the Administrator stated she was a LPN, and that she had a food service certificate, not a food services degree.

Based on observations and interviews, it was determined the facility failed to treat each resident with respect and dignity that promoted enhancement of his/her quality of life and dining experience. This deficiency created the potential for psychosocial harm if the residents felt excluded from the dining experience. This was true for 3 of 24 residents (#1, #17, and #28) who were observed eating in the dining room. The findings include: The facility posted the following meal times for the dining room: Breakfast: 7:30 AM Lunch: 12:00 PM Dinner: 5:30 PM The following residents did not receive their meal in a timely manner, or did not receive their meal at the same time as the other residents at the same table: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses including GERD, multiple sclerosis, and depression. Resident #17 was admitted to the facility on [DATE] with multiple diagnoses including heart failure, hypertension, and end stage renal disease. Resident #28 was admitted to the facility on [DATE] with multiple diagnoses including anemia, hyperlipidemia, Alzheimer's disease, and dementia. On 9/22/24, the following was observed in the dining room: - At 12:40 PM, Resident #1 was observed eating her meal at a table with two other residents (#17 and #28). - At 12:45 PM, Resident #17 received his meal and the feeding aide sat next to him to assist him. - At 12:49 PM, Resident #28 received her regular meal, but it was removed as she needed a mechanical chopped meal. - At 12:53 PM, Resident #28 received her mechanical chopped meal. - At 12:55 PM, with the assistance of a feeding aide, Resident #28 began eating. On 9/24/24 at 8:15 AM, the DM stated that meal orders are filled based on the meal tickets received and no one knows who is sitting where until the dining has started. Meal orders are filled, and facility staff take the completed trays out to the residents. Facility staff try to feed the residents together, but it does not always work that way.

Based on observation, policy review, and staff interview the facility failed to ensure staff provided meal service according to the facility's posted mealtime schedule. This failure created the potential for 69 residents to experience poor quality of life, potential nutritional issues, and complications with medications required to be taken with meals if waiting more than 45 minutes to receive their meals. Findings include: A posted dining schedule at the front entrance of the facility documented: - Breakfast at 7:30 AM - Lunch at 12:00 PM - Dinner at 5:30 PM On 9/22/24 at 12:30 PM, during the lunch dining room observation, residents were seated for the lunch meal at 12:00 PM. At 12:35 PM it was observed that the first tray of food was delivered to residents in the dining room. The last meal was delivered to dining room residents was at 12:53 PM. On 9/24/24 at 8:00 AM, the following was observed during the second kitchen inspection: - 7:30 PM - Residents are seated in the dining room for their breakfast meal. - 8:00 AM - Dining room service begins. - 8:07 AM - Meal service begins for North Hall residents. - 8:25 AM - Meal service begins for the East Hall residents. - 8:46 AM - Meal service begins for the South Hall residents. On 9/24/24 at 3:15 PM, the DM and RD (Registered Dietitian) reviewed the posted dining mealtimes at the front of the facility. Both stated they were not familiar with the posted mealtimes. The DM and RD stated the actual facility mealtimes were different from the posted mealtimes.

Based on observation and staff interview, it was determined the facility failed to ensure the kitchen equipment and environment was maintained, clean, and food was stored in a safe and sanitary manner. These deficiencies had the potential to affect the 69 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: The FDA (Food Drug Administration) Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, states 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. The FDA Food Code Section 6-501.12 Cleaning, Frequency and Restrictions, states cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when foods are in protected storage and when food is not being served or prepared. 1. The initial kitchen inspection was conducted on 9/22/24 at 12:03 PM, the following was observed: - Bowled noodle soup placed on counter, no heat or time stamp. - Bowled salad on counter, no ice or time stamp. - Ice buildup in freezer on ceiling. - Three inches of ice growing up from a cardboard food box, under one inch of ice growing down from shelf. - Open and undated, Stir-fry veggies and carrot coins. - Open and undated, ice cream sandwiches. - Two large ice cream container lids were not sealed and open directly under freezer ceiling. - In the refrigerator, the following were undated and unlabeled: noodle soup, shredded carrots, and a container of noodle/macaroni spiral salad. - A fully cooked ham was placed on top of the liquid eggs. - A brown layer of dirt was around the AC unit and across the ceiling. Directly below were open and undated bags of shredded lettuce, and an open container of dry, grated parmesan cheese. 2. A second kitchen inspection was conducted on 9/24/24 at 2:55 PM with the NSD (Nutritional Services Director). The following was observed: - Ice buildup in freezer on ceiling in the form of droplets. - Three inches of ice growing up from a cardboard food box, under one inch of ice growing down from shelf. - Two large ice cream containers lids were not sealed and open directly under freezer ceiling. - In the refrigerator, a brown layer of dirt was around the AC unit, and across the ceiling. A review of the September 2024 [NAME] AM/PM Cleaning Duty schedule documented that the freezer floor was cleaned on all but the following dates: 9/1/24 and 9/13/24 during the AM shift, and from 9/1/24 - 9/6/24 during the PM shift. On 9/24/24 at 3:13 PM, the DM stated that maintenance completes the cleaning of the refrigerator and freezer units if there are issues with the air conditioner or freezer units. Kitchen cleaning is done daily, but deep cleaning is done monthly, if not quarterly. The ice buildup happens because the freezer door doesn't close well. The ice is usually cleaned up daily. On 9/24/24 a work history report from maintenance was provided that documented the refrigerator and freezer condenser coils were inspected and cleaned on 9/20/24 by the maintenance director. On 9/25/24 at 11:45 AM, the maintenance director was shown the ceiling in the refrigerator and the ice buildup in the freezer, he stated that he only checked the equipment. The cleaning of the refrigerators and freezers are supposed to be completed by the kitchen staff.

Based on observation and staff interview, it was determined the facility failed ensure Activity Room has adequate and comfortable lighting for the residents to enjoy their activity. This failure had the potential for residents to experienced psychosocial harm if they were unable to perform their independent functioning and task performance. Findings include: On 9/23/24 at 2:50 PM, Resident #40 asked the surveyor to visit the Activity Room. On 9/23/24 at 2:59 PM, the facility's Bistro which was being use by the facility as their Activity Room was observed to have dim lighting. There were missing light bulbs and multiple lights were out on the track lighting. On 9/24/24 at 2:26 PM, the Maintenance Director stated he was unable to replace the light tracks because it was no longer available in the area. The Maintenance Director stated he reported it to the previous administrator, and he was told it would be replaced during the remodeling of the facility. On 9/24/24 at 2:41 PM, the Activity Director (AD) stated residents expressed concerns about the lighting in the Activity Room especially when they are doing their activities such as working on their jigsaw puzzles. The AD also stated it was not easy for her to apply nail polish to the residents. On 9/24/24 at 3:08 PM, the Interim DON stated the track lightings were not replaced because they were waiting for the remodeling of the facility.

Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to respect and maintain a resident's dignity by placing a sign related to care outside their room door. This was true for 1 of 13 residents (Resident #38) who were reviewed for dignity. This deficient practice created psychosocial harm for Resident #38 when he expressed he felt like a bad person and felt very bad about it all of the time with the placement of the sign. Findings include: The facility's policy Resident Rights, revised January 2017, stated, The center recognizes the resident's right to a quality of life that supports privacy, confidentiality, independent expression, choice, and decision making, consistent with State law and Federal regulation. The center promotes the resident right to a dignified existence, self-determination, and communication . This policy was not followed. Resident #38 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #38's care plan for ADLs, initiated on 5/15/19, included an intervention for staff to provide cares with pairs, indicator on the resident door frame. Resident #38's record included a progress note, dated 9/18/21 at 2:52 PM, documenting Resident #38 was cared for in pairs (meaning two staff members should be with Resident #38) due to accusations he had made toward staff. On 10/20/21 at 2:55 PM, the right side of Resident #38's door frame had a sign posted at eye level with images of two smiling pears holding hands. Resident #38 said the facility put the pear sign on his door frame many years ago. He said it instructed staff to be a pair of two people to go into his room to provide any care or services. Resident #38 said the sign made him feel he was a bad person when he saw it. He said he talked to the Administrator, and nothing had changed. Resident #38 said he felt very bad about it all the time. On 10/20/21 at 5:00 PM, RN #1 said the pear sign meant pairs for care. She said it was for residents who required two staff to provide care. RN #1 said Resident #38 had the sign because he made comments or accusations toward staff members. On 10/22/21 at 9:25 AM, the DON said the sign with the pears on Resident #38 's door frame started about two or three years ago. He said it meant Resident #38 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said that was why the facility put the sign on his door to remind staff to provide care in his room with another staff member present. The DON said he was not aware Resident #38 was feeling bad each time he saw it and felt he was a bad person with the pear sign.

Based on observation, staff interview, policy review, review of the facility's employee screening logs, work schedules, and time sheets, it was determined the facility failed to ensure infection control prevention practices were implemented and maintained to prevent and contain COVID-19. This failure resulted in the likelihood of serious harm, impairment, or death to all staff and the 58 residents in the facility. Findings include: 1. The facility's COVID-19 policy, updated 7/13/20, documented the facility would provide a COVID-19 positive unit that was separated by a physical barrier from other areas of the facility. The policy also documented the facility would have designated staff for that unit, and the facility would follow CDC guidelines. The CDC website, accessed on 7/31/20, Responding to Coronavirus in Nursing Homes, documented facilities were to assign dedicated healthcare professionals to work only on the COVID-19 care unit. This policy and the guidelines were not followed. The facility's North hall was separated with a plastic barrier which covered floor to ceiling and wall to wall located between room [ROOM NUMBER] and room [ROOM NUMBER] on the right side of the hall and between room [ROOM NUMBER] and room [ROOM NUMBER] on the left side of the hall. The North section, beyond the barrier housed residents who had tested positive for COVID-19 and the residents South of the barrier housed residents who had tested negative for COVID-19. The facility's COVID-19 surveillance and tracking form, dated 7/9/20 to 7/20/20, documented test results for Residents #1 - #4 and #24 - #29, who resided in the North hall between the plastic barrier and the back door. These residents had tested positive for COVID-19. The facility's COVID-19 surveillance and tracking form, dated 7/20/20 to 7/24/20, documented test results for Residents #11 - #19, who resided in the North hall between the fire doors and the plastic barrier. These residents had tested negative for COVID-19. The facility's daily assignment sheets, dated 7/24/20 to 7/28/20, documented CNA and Nurse staff assignments for the North hall. The sheets had documented all staff working each shift for that hallway. There was no indication that staff assignments were designated for the COVID-19 positive unit and COVID-19 negative unit of the hallway. On 7/28/20 at 9:25 AM, CNA #7 was on the North hall COVID-19 positive unit and unzipped one of two zippers on the plastic barrier and walked through to the COVID-19 negative unit, zipped closed the barrier and went into Residents #13's and Resident #14's room. At 9:32 AM, CNA #7 came out of the room with a used incontinent brief in a trash bag and disposed of it, doffed (took off) her gloves, and performed hand hygiene and donned (put on) new gloves. CNA #7 then unzipped the zipper on the plastic barrier and went back into the COVID-19 positive unit. At 9:42 AM, CNA #7 and CNA #9 went into Resident #24's and Resident #25's room and made the bed of Resident #25. On 7/28/20 at 10:15 AM, CNA #7 and CNA #8 were in the hallway of the COVID-19 negative unit of the North hall. At 10:20 AM, CNA #7 went into Resident #19's room and came out with a disposable meal carton, disposed of it, performed hand hygiene, and donned new gloves. At 10:25 AM, CNA #7 then went back into the COVID-19 positive unit and closed the zipper on the barrier. At 10:26 AM, CNA #8 went into the COVID-19 positive unit after she unzipped and then closed the zipper on the barrier. At 10:34 AM, CNA #7 and CNA #8 left the COVID-19 positive unit and went into the negative unit and went into Resident #13's and Resident #14's room. At 10:37 AM and 10:40 AM, respectively, CNA #8 and CNA #7 left Residents #13's and Resident #14's room and went into Resident #12's room. On 7/28/20 at 10:39 AM, LPN #2 left the medication cart in the COVID-19 negative unit and went into the COVID-19 positive unit through the plastic barrier in the North hall. At 11:02 AM, LPN #2 came back through the plastic barrier from the COVID-19 positive unit to the COVID-19 negative unit and to the medication cart. On 7/28/20 at 10:45 AM, CNA #8 came out of Resident #12's room and went into Resident #13's and Resident #14's room. On 7/28/20 at 10:46 AM, CNA #7 left Resident #12's room and went into Resident #15's and Resident #16's room. On 7/28/20 at 10:50 AM, CNA #9 came through the barrier from the COVID-19 positive unit and into the COVID-19 negative unit in the North hall. On 7/28/20 at 9:20 AM, LPN #2 said she was the nurse for both the COVID-19 positive and COVID-19 negative units in the North hall. She said the facility did not have dedicated staff for the COVID-19 positive unit. On 7/28/20 at 9:55 AM, CNA #7 and CNA #9 said staff helped each other out and worked the whole North hall on both sides of the barrier. They said the facility had enough staff to take care of the residents' needs. On 7/28/20 at 10:52 AM, CNA #8 said she worked the whole North hall on both sides of the barrier. She said the facility had enough staff to take care of the residents' needs. On 7/28/20 at 1:05 PM and 4:35 PM, the Staffing Coordinator said the facility assigned dedicated CNAs to the COVID-19 positive unit and those staff should not work the COVID-19 negative unit. She said a nurse was assigned to work both the COVID-19 positive and COVID-19 negative units in the North hall. The Staffing Coordinator said the facility had enough consistent staff and had not altered staffing schedules even after residents began testing positive for COVID-19. On 7/28/20 at 1:15 PM, the Administrator said CNAs should not work both the COVID-19 positive and COVID-19 negative unit in the North hall or go between the barriers. She said due to lack of nurses the facility did not have a dedicated nurse in the North hall COVID-19 positive unit. On 7/28/20 at 4:45 PM, CNA #10 said she worked the whole North hall on both sides of the barrier. On 7/28/20 at 5:02 PM, CNA #11 said she would help in both the COVID-19 positive and COVID-19 negative units in the North hall if her co-workers needed help. On 7/29/20 at 2:00 PM, RN #1 said she was the nurse for the whole North hall during her shift. On 7/29/20 at 2:45 PM, the ICP said the facility tried to maintain dedicated staff for the COVID-19 positive unit. She said the same nurse worked both the COVID-19 positive and COVID-19 negative units in the North hall due to lack of staff. Due to conflicting interviews, it was unclear if the facility had tried to mitigate staff shortages to provide dedicated staff to the COVID-19 positive unit in the North hall, specifically nurses. 2. The CDC website, accessed on 7/31/20, Preparing for COVID-19 in Nursing Homes, stated facilities were to screen all staff at the beginning of their shift for fever and symptoms of COVID-19, have staff leave work if they are ill, and staff with a positive screening at entry were to leave the facility. This guideline was not followed. The facility's Staff Temperature Attestation Logs from 7/24/20 to 7/28/20, directed staff to take and record their own temperature and answer yes or no if they had respiratory symptoms such as difficulty breathing, sore throat, cough, congestion, nausea, vomiting, diarrhea, chills, fever, shortness of breath, muscle aches, malaise, change in ability to taste or smell and/or runny nose, and to sign the log. The facility's hourly employee time sheets from 7/24/20 to 7/28/20 were reviewed and compared with the employee Staff Temperature Attestation Logs from the same dates. The following inconsistencies were identified. Staff were identified who worked without being screened prior to the beginning of their shift. * The screening logs and time sheets, dated 7/24/20, documented 4 CNAs, 4 LNs, and 2 administrative staff were not screened prior to working their shifts. * The screening logs and time sheets, dated 7/25/20, documented 2 CNAs, 2 LNs, 1 Hospitality Aide, and 1 administrative staff were not screened prior to working their shifts. * The screening logs and time sheets, dated 7/26/20, documented 7 CNAs, 1 Hospitality Aide, and 1 LN were not screened prior to working their shifts. * The screening logs and time sheets, dated 7/27/20, documented, 2 LNs, 1 CNA, and 1 administrative staff were not screened prior to working their shifts. * The screening logs, and time sheets for day shift, dated 7/28/20, documented 2 LNs were not screened prior to working their shifts. On 7/28/20 at 9:54 AM, CNA #1 said he came to work at 6:00 AM and took his own temperature, and answered questions in the screening log. CNA #1 said he donned a gown, N95 respirator mask, and goggles and went to the South hall. On 7/28/20 at 10:12 AM, Laundry Aide #1 said she took her temperature before coming to work, but forgot to check herself in. Laundry Aide #1 said she donned a gown, a mask, and goggles and collected the dirty gowns and washed them. On 7/28/20 at 10:28 AM, the Dietary Manager and Cook #1 both said they checked their own temperatures and answered the questions in the screening log. On 7/28/20 at 10:30 AM, the Graduate Nurse said she took her own temperature. On 7/28/20 at 10:33 AM, BOM said she came to work around 7:00 AM and took her own temperature and answered the questions in the screening log and checked herself in. On 7/28/20 at 10:35 AM, CNA #2 said she took her own temperature and answered the questions in the screening log. On 7/28/20 at 10:57 AM, CNA #3 said she took her own temperature and answered the questions in the screening log. On 7/28/20 at 11:52 AM, CNA #9 said he checked himself in, answered the questions on the screening log, and took his own temperature before each shift. On 7/28/20 at 11:55 AM, CNA #8 said she checked herself in, answered the questions on the screening log, and took her own temperature before each shift. On 7/28/20 at 11:59 AM, the LSW said she checked her temperature before leaving her home and believed she answered the questions in the screening log. On 7/28/20 at 12:00 PM, LPN #2 said she checked herself in, answered the questions on the screening log, and took her own temperature before each shift. On 7/28/20 at 4:45 PM, CNA #10 said she checked herself in at the back door, answered the questions on the screening log, and took her own temperature before each shift. On 7/29/20 at 1:55 PM, CNA #11 came into the facility through a back door and proceeded to check her own temperature and filled out the screening log without any other staff's assistance. CNA #1 said she always checked herself in. On 7/29/20 at 2:00 PM, RN #1 came into the facility through a back door and proceeded to check her own temperature and filled out the screening log without another staff's assistance. RN #1 said she always checked herself in. On 7/29/20 at 2:45 PM, the ICP said she expected staff to screen themselves before each shift, take their own temperatures, and record signs and symptoms of COVID-19. She said she thought self-screening of staff was allowed. The ICP said when they were in the facility, she, the DON, or the Administrator reviewed the screening logs to make sure staff who worked did not have fevers and/or COVID-19 symptoms. She said she did not check the logs to see if staff who worked had screened themselves before their shifts. On 7/29/20 at 3:40 PM, the Administrator said she thought staff could screen themselves. 3. The facility's COVID-19 policy, updated 7/13/20, directed staff to dispose of gowns before leaving a COVID-19 positive room. The policy also directed staff to put on clean gloves upon entry into resident rooms. The facility's Hand Hygiene policy, revised 08/2019, directed staff to perform hand hygiene before and after using gloves and after contact with residents or objects in their environment. The facility's Transmission-Based Precautions policy, revised 10/2018, directed staff to place signs and instructions on residents' doors who were in isolation precautions. These policies were not followed. The facility's in-service training, dated 7/11/20, directed staff to wear a disposable gown over the top of a washable gown in COVID-19 positive rooms and then dispose of the disposable gown when leaving the room. The facility's in-service training, dated 7/23/20 and 7/24/20, directed staff they could wear the same gown when in COVID-19 positive rooms and to remove the gown when they left the hallway. The training sign-in sheet did not document CNA #9, CNA #10, and CNA #11 had received this training. a. On 7/28/20 at 8:48 AM, the Administrator informed the surveyor that after the surveyor was in the North side of the plastic barrier in the North hall, the surveyor was expected to doff the gown and gloves and leave out the back door and then to walk around the building and don new PPE at the front entrance. The Administrator said to not go back through the building via the plastic barrier. The following were observed in the North hall on 7/28/20: On 7/28/20 at 9:25 AM, CNA #7 was on the North hall COVID-19 positive unit and unzipped one of two zippers on the plastic barrier wearing gloves and a red reusable PPE gown and walked through to the COVID-19 negative unit, zipped closed the barrier and went into Resident #13 and #14's room with the same gown and gloves. At 9:32 AM, CNA #7 came out of the room with a used incontinent brief in a trash bag and disposed of it and performed hand hygiene and donned (put on) new gloves and kept the same gown on. CNA #7 then unzipped the zipper on the plastic barrier and went back into the COVID-19 positive unit. CNA #7 then took a red used reusable gown off a hook in the hallway in the COVID-19 positive unit and placed it over the top of the red reusable gown she had worn prior to and after leaving the COVID-19 negative unit. CNA #7 said each staff had a dedicated gown in the COVID-19 positive unit and used those in residents' rooms on the unit. CNA #7 said staff were to double gown when in the COVID-19 positive unit. On 7/28/20 at 9:33 AM, CNA #7 instructed the surveyor to place a clean red reusable gown over the top of the green reusable gown the surveyor had worn into the COVID-19 positive unit. CNA #7 said after the surveyor was done in the COVID-19 positive unit they had to doff the gown and gloves and leave out the back door and then to walk around the building and don new PPE at the front entrance. On 7/28/20 at 9:42 AM, CNA #7 and CNA #9 went into Resident #24's and Resident #25's room in the COVID-19 positive unit and made Resident #25's bed. CNA #7 and CNA #9 had two reusable gowns on. CNA #7 had two red reusable gowns on and CNA #9 had a green reusable gown with a red gown on top of it. On 7/28/20 at 10:15 AM, CNA #7 and CNA #8 were in the hallway of the COVID-19 negative unit on the North hall and each were wearing a red reusable gown. At 10:20 AM, CNA #7 went into Resident #19's room and came out with a disposable meal carton, disposed of it, performed hand hygiene, and donned new gloves. At 10:25 AM, CNA #7 then went back into the COVID-19 positive unit with the same gown on and closed the zipper on the barrier. At 10:26 AM, CNA #8 went into the COVID-19 positive unit with the same gown on and then closed the zipper on the barrier. At 10:34 AM, CNA #7 and CNA #8 left the COVID-19 positive unit into the negative unit wearing red reusable gowns and gloves and went into Residents #13 and #14's room with the same gown and gloves on. At 10:37 AM and 10:40 AM, respectively, CNA #8 and CNA #7 left Resident #13 and #14's room with the same gowns, doffed their gloves, performed hand hygiene, donned new gloves and went into Resident #12's room. On 7/28/20 at 10:45 AM, CNA #8 left Resident #12's room with the same gowns, doffed her gloves, performed hand hygiene, donned new gloves and went into Residents #13 and #14's room with the same gowns on. On 7/28/20 at 10:46 AM, CNA #7 left Resident #12's room with the same gowns, doffed her gloves, performed hand hygiene, donned new gloves and went into Residents #15 and #16's room with the same gowns on. On 7/28/20 at 10:39 AM, LPN #2 left the medication cart in the COVID-19 negative unit and went into the COVID-19 positive unit through the plastic barrier in the North hall wearing a green reusable gown. At 11:02 AM, LPN #2 came back through the plastic barrier from the COVID-19 positive unit to the COVID-19 negative unit and to the medication cart wearing the same green reusable gown. At 11:02 AM LPN #2 said she had just been in the COVID-19 positive area and had placed a reusable gown over the top of her green reusable gown. She said she had worn the green gown in both units. On 7/28/20 at 11:52 AM, CNA #9 came through the barrier from the COVID-19 positive unit and into the COVID-19 negative unit in the North hall wearing a green reusable gown. On 7/28/20 at 4:58 PM, the COVID-19 positive unit in the North hall had three hooks on the walls with a red reusable gown on each hook. The inside area of two of the gowns were exposed to the hallway air. On 7/28/20 at 9:28 AM, LPN #2 said staff were supposed to doff PPE when leaving the COVID-19 positive unit and before entering the COVID-19 negative unit in the North hall. LPN #2 said staff were to don new gowns and gloves after entering the COVID-19 negative unit and pointed to an empty area in the hallway just inside the unit and said there should have been a PPE cart there but there was not. On 7/28/20 at 9:55 AM, CNA #7 and CNA #9 said they used the same reusable gown for both the COVID-19 positive and COVID-19 negative units in the North hall. CNA #7 and CNA #9 said they put on used gowns dedicated for their individual use, that hung in the COVID-19 positive hallway, over the top of the gowns they wore in both the COVID-19 positive and COVID-19 negative units. On 7/28/20 at 10:52 AM, CNA #8 said she used the same reusable gown for both the COVID-19 positive and COVID-19 negative units in the North hall. CNA #8 said she put on a used gown, that hung in the COVID-19 positive hallway, over the top of the gown she wore in both the COVID-19 positive and COVID-19 negative units. On 7/28/20 at 4:45 PM, CNA #10 said she used the same reusable gown for both the COVID-19 positive and COVID-19 negative units in the North hall. CNA #10 said she put on a used gown, that hung in the COVID-19 positive hallway, over the top of the gown she wore in both the COVID-19 positive and COVID-19 negative units. On 7/28/20 at 5:02 PM, CNA #11 said she was told by another CNA that while in the COVID-19 positive unit she could wear a disposable gown over the top of her reusable gown. CNA #11 said after she disposed of the top gown, she would go into the COVID-19 negative unit with the reusable bottom gown that she wore in both units. b. The facility placed their COVID-19 negative residents and residents whose COVID-19 test results were pending in the South hall unit. Staff wore protective gowns, masks, and a face shields or goggles. The following were observed in the South hall on 7/28/20: At 9:20 AM, CNA #1 was inside Residents #1 and #2's room. Two gowns (one red and one white) were observed hung on the wall. CNA #1 was wearing a green gown, goggles, and an N95 respirator mask. CNA #1 stripped the sheets of Residents #1's and Resident #2's bed with his gloved hands. CNA #1 also removed the pillow cases of Residents #1's and Resident #2's pillows. CNA #1 then placed the white sheets and pillow cases inside a clear plastic bag and tied it in a knot. CNA #1 said Residents #1 and #2 were transferred to the COVID-19 positive unit. CNA #1 said he would also strip the beds of Resident #3 and #4 after he was done with Residents #1 and #2's beds. At 9:29 AM, CNA #1 was wearing a green gown and entered Resident #3's and Resident #4's room. Two red gowns were observed hanging on the wall. CNA #1 then performed hand hygiene and put on new gloves. CNA #1 then stripped the sheets of Residents #3's and Resident #4's beds. CNA #1 also removed the pillow cases of Residents #3's and Resident #4's pillows. CNA #1 then placed the white sheets and pillow cases inside a clear plastic bag and tied it in a knot. CNA #1 said Residents #3 and #4 were transferred to the COVID-19 positive unit the day before. CNA #1 then removed his gloves, performed hand hygiene and carried the plastic bags to the soiled utility room. At 9:41 AM, CNA #1 entered Residents #5's and Resident #6's room wearing the same green gown and came out with a disposable food tray and threw it away in a big blue trash can. CNA #1 then removed his gloves and performed hand hygiene. At 9:42 AM, CNA #1 entered Residents #7's and Resident #8's room wearing the same green gown and closed the door. At 9:44 AM, CNA #1 exited Resident #7's and Resident #8's room and entered the shower room with the same green gown. On 7/28/20 at 9:54 AM, CNA #1 said he came to work at 6:00 AM and wore the green gown, goggles and N95 respirator mask at the Bistro entrance of the facility after checking himself in. CNA #1 said he kept the same gown during his entire shift unless it was soiled then he would change his gown. CNA #1 and the surveyor then went to Residents #1's and Resident #2's room and to Resident #3's and Resident #4's rooms afterwards. CNA #1 said he believed he used the gown that was hanging on the wall inside Residents #1 and #2's rooms and Resident #3's and Resident #4's rooms to put over his green gown when he stripped the bedsheets off their beds. CNA #1 said he did not know how long those gowns were there and he did not know who else used them. CNA #1 said it was the Staffing Coordinator who trained him in donning and doffing of PPE. c. On 7/28/20 at 1:10 PM, Resident #28's door had a hanging device which contained PPE including disposable gowns, face masks, and gloves. A STOP sign which stated to see the nurse before entering the room was posted below the hanging device. The SSA was inside Resident #28's room and was wearing a green gown, gloves, face mask, and a face shield. She placed the personal belongings, including the luggage of Resident #28, in one corner of her room. The SSA then removed her gloves and performed hand hygiene and kept her green gown on. The SSA then walked out of the South hall with her green gown, face mask, and face shield on. On 7/28/20 at 1:20 PM, the Graduate Nurse said Resident #28 was in the hospital and tested positive for COVID -19. The Graduate Nurse said Resident #28 would be readmitted to the COVID-19 unit and the SSA was putting all her personal belongings together and would bring them to the COVID-19 unit. On 7/28/20 beginning at 1:45 PM, the SSA had a cart and walked toward Resident #28's room. The SSA performed hand hygiene and donned a pair of gloves before she entered Resident #28's room. When the SSA came out of Resident #28's room, she had Resident #28's personal belongings inside the cart. The SSA removed her gloves and performed hand hygiene and walked through the back door. The SSA said she entered Resident #28's room two times and she did not put another gown on top of her green gown. The SSA said she was directed to put on another gown on top of the gown she was wearing before entering residents' rooms with actual or suspected cases of COVID-19 and she did not do it. d. On 7/28/20 at 4:53 PM, CNA #4 entered Residents #9 and #10's room and took the residents' temperatures. CNA #4 did not put on another gown on top of her green gown. On 7/28/20 at 5:09 PM, CNA #4 entered Residents #20's and Resident #21's room and took their vital signs wearing the same green gown when she entered Resident #9's and Resident #10's room. On 7/28/20 at 5:14 PM, CNA #4 said she did not want to wear the gowns that hung inside Residents #9 and 10's room because she did not know who else had used them. On 7/28/20 at 4:59 PM, LPN #1 said Residents #9 and #10 had been tested for COVID-19 and the results were pending. LPN #1 said staff should wear another gown on top of their gowns when they enter Residents #9's and Resident #10's room. LPN #1 said Resident #9 had complained of a sore throat and of being tired. She said Resident #10 had hoarseness in her voice. On 7/28/20 at 5:15 PM, CNA #1 said he thought the night shift hung the two gowns inside Residents #9 and #10's room and could be reused by the staff to put over their gowns when they entered the room. CNA #1 said he believed those gowns could be used by morning and evening shift staff unless it was soiled. On 7/29/20 at 2:00 PM, LPN #1 said Resident #9 and Resident #10 tested positive for COVID-19 and they were transferred to the COVID-19 positive unit. e. On 7/28/20 at 12:10 PM, two gowns, one red and one white, were observed hanging on the wall inside Resident #9's and Resident #10's room. CNA #2 said Resident #9 and Resident #10 were tested for COVID-19 and the results were pending. CNA #2 said they were instructed to put another gown on top of the gown they were already wearing when they entered their room. On 7/28/20 at 1:30 PM, CNA #3 had a green gown, gloves, respirator mask, and face shield on while talking to Resident #10 inside their room. CNA #3 had no other gown on top of her green gown. CNA #3 then removed her gloves and performed hand hygiene before she exited Resident #10's room. CNA #3 then entered Resident #23's room, who tested negative for COVID-19. On 7/28/20 at 1:32 PM, CNA #3 said she had gone into Resident #10's room and gave her ice cream. CNA #3 said she was aware Resident #10's COVID-19 test was pending and she should have put another gown over her green gown. CNA #3 said it was the Staffing Coordinator who trained her in donning and doffing of PPE. On 7/28/20 at 4:59 PM, LPN #1 said there should be a STOP sign to see the nurse and PPE cart before entering their room. LPN #1 and the surveyor then went to Resident #9 and #10's room. LPN #1 said she did not know why Residents #9 and #10's room did not have a STOP sign to see the nurse and a PPE cart at their door. On 7/28/20 at 5:14 PM, CNA #4 said she knew Resident #9 and Resident #10 had their COVID-19 test done and the results were pending. CNA #4 said she should have put another gown on top of her green gown when she entered their room but she forgot. CNA #4 said if there was a sign and a PPE cart outside the door it would have reminded her to wear another gown over her green gown. f. The facility had a COVID-19 positive unit on the East hall. The entrance to the hall had a plastic barrier with a zipper down the middle. Observations were conducted in this hall on 7/28/20 from 9:00 AM to 11:15 AM. At 9:00 AM, CNA #11 was wearing a pair of gloves and went and grabbed a new clean pair from a box on top of a cart in the hallway. CNA #11 then went and removed the gloves she was wearing and threw them in the trash and applied the new clean pair of gloves without performing hand hygiene. At 9:02 AM, the Hospitality Aide was getting gloves to enter a resident room. She went into the resident's room while still putting on the gloves. After speaking with the resident, the Hospitality Aide removed her gloves prior to exiting the room and did not perform hand hygiene. She then grabbed another pair of clean gloves from a box and put them on. Beginning at 9:10 AM, CNA #12 exited a resident's room, with gloves on, went to a trash can in the hallway and opened the lid and threw away some trash. CNA #12 then entered another resident's room with the same pair of gloves and exited a short time later with a disposable food tray and threw it away in the trash. CNA #12 did not remove her gloves or perform hand hygiene. CNA #12 then went to a phone, located on the wall in the middle of the hallway, and placed a call using the same pair of gloves. CNA #12 then grabbed a clean face mask from a box and placed it on a resident. She then went to the clean laundry cart, located in the hallway, grabbed 2 clean wash cloths and gave them to the Hospitality Aide. CNA #12 did not change her gloves or perform hand hygiene during this time. At 9:22 AM, the Hospitality Aide went to the plastic barrier while wearing gloves, unzipped it halfway and was speaking to another staff on the other side. She received a stack of clean towels from the staff person on the other side of the barrier. The Hospitality Aide opened the door to the shower room and went in with the towels. She exited a short time later with half the stack of towels still in her hands, she was wearing the same gloves. The Hospitality Aide then walked down the hallway to where the clean linen cart was located and placed the remaining clean towels into the cart. The Hospitality Aide did not change her gloves or perform hand hygiene. At 9:23 AM, the Hospitality Aide went into a resident's room for a short time and exited with the same gloves. She went to the plastic barrier again and unzipped it halfway and someone on the other side handed her a meal in a to-go box with plastic silverware and a napkin on top of the box. She placed her right gloved hand on top of the silverware and napkin and held the box underneath with her left hand. The Hospitality Aide went into a resident's room to give them the food. She did not change her gloves or perform hand hygiene. On 7/28/20 at 11:04 AM, the Hospitality Aide stated she had worked in the facility since June 2020. She stated she did not have specific training on infection prevention but followed a mentor for a day. On 7/29/20 at 2:00 PM, CNA #12 stated infection prevention training was done usually at the end of the shift in a small group or huddle. She stated training was done by the Administrator, DON, ICP, and Staffing Coordinator. CNA #12 said she was asked if she knew the steps she was trained to first and then was observed performing them and it was checked off. She stated hand hygiene should be done before and after performing care and when putting on and taking off gloves. CNA #12 said hand hygiene should also be performed between residents and in between resident rooms. On 7/29/20 at 2:05 PM, LPN #3 said the Staffing Coordinator provided training to staff on that day. He said for less experienced staff, the Staffing Coordinator or ICP watched and helped them with putting on and taking off PPE, but for those staff with more experience, It's more we check it off on a piece of paper and sign it. On 7/28/20 at 1:15 PM, the Administrator stated hospitality aides were used to assist CNAs. She stated they were trained on donning and doffing of PPE, assisting with Hoyer (mechanical lift) transfers, and assisting with dining. The Administrator stated hospitality aides were not to obtain or report vital signs. On 7/29/20 at 2:45 PM, the ICP said staff were trained to double gown while on the COVID-19 positive unit or in a COVID-19 positive room. She said she could not find that guidance from the CDC, did not think it was in the facility's policy and thought it had come from the Staffing Coordinator. The ICP said she expected staff to doff their gloves and all of their gowns before they re-entered the COVID-19 negative unit from the COVID-19 positive unit. The ICP said in the South hall, she expected staff to remove both gowns after exiting residents' rooms who were in precautions and put a new gown on before entering another resident's room. She said staff should not have worn the same gown or gloves in both the COVID-19 positive and COVID-19 negative units because they could be contaminated with COVID-19 and could pass it to residents who were COVID-19 negative. The ICP said multiple staff should not reuse the same gown to put over their gowns. She said a Stop sign to see the nurse and a PPE cart should have been placed outside of Residents #9's and Resident #10's room. The ICP said she expected staff to perform hand hygiene after doffing gloves. 4. The facility's COVID-19 policy, updated 7/13/20, documented the facility's designated unit for residents who were COVID-19 positive was to be separated by a physical barrier from other areas of the facility. This policy was(TRUNCATED)

Based on record review, policy review, review of facility Incident and Accident reports, resident interview and staff interview, it was determined the facility failed to ensure residents were free from intimidation when reporting abuse for 1 of 18 residents (#176).This failure resulted in psychosocial harm due to fear of intimidation and retaliation by the facility in reporting abuse and neglect by staff. Findings include: The facility's policy, Prevention and Reporting: Abuse, Neglect and Mistreatment, dated February 2018, defined abuse as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It further defined mental abuse as verbal or non-verbal and included humiliation, harassment, and threats of punishment or deprivation. The policy stated residents had the right to be free from abuse, neglect, and exploitation. This policy was not followed. Resident #176 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 12/10/19, stated Resident #176 was cognitively intact. An Incident and Accident Report, dated 8/25/19, documented on 8/24/19, Resident #176 reported to an unnamed CNA that Staff Member A was rough during cares. Resident #176 stated Staff Member A smacked his forehead against the side rails of the bed and smacked and pinched his scrotum with the urinal. It was documented in the report Resident #176 stated he did not want to say anything, because he was worried it would make things worse for him in the facility. Resident #176's care plan, dated 8/26/20, stated Resident#176 had a potential concern for psychosocial well-being related to accusations of abuse. The interventions documented were as follows: * allow Resident #176 to verbalize perceptions and fears * protect Resident #176 * offer reassurance * use positive conversation * rule out abuse/pain * report allegation An undated follow up interview in the Incident and Accident Report documented Resident #176 stated he had a verbal disagreement with Staff Member A. It documented Staff Member A turned Resident #176 and bumped his head on the siderail unintentionally. The report also documented when Staff Memer A was providing cares, the urinal also unintentially pinched Resident #176's thigh. The report documented Resident #176 stated during the undated follow up interview he felt safe in the facility and denied any abuse. On 3/2/20 at 10:50 AM, Resident #176 stated There is a lot going on here that is just not good. Resident #176 stated he had a copy of the investigation report and They minimized what I said. Resident #176 stated there was a staff member, Staff Member A, that was just really, really, bad. He stated Staff Member A went to turn him and banged his head against the rails over and over. Resident #176 stated Staff Member A then took the urinal and smashed it against his genitals over and over. Resident #176 stated he got thumped up pretty good by Staff Member A and the facility sent Staff Member A to another hall to work. Resident #176 stated what Staff Member A was doing was not right and he only felt safe once Staff Member A left the facility. Resident #176 stated the facility fired Staff Member A after another resident complained of abuse. Resident #176 stated he contacted the local Ombudsman at the time, but then changed his mind about discussing the incident when the local Ombudsman asked for information because he was afraid of repercussions from staff. On 3/5/20 at 9:44AM, Resident #176 reported he thought the abuse started because he was telling Staff Member A he shot the biggest bear in Idaho and he called BS on me. Resident #176 stated a couple of days later Staff Member A was turning him in bed and Staff Member A hit his head on the siderail really hard. Resident #176 stated Staff Member A then grabbed his shoulders and hit his head against the siderails over and over, really hard, an unknown amount of times. Resident #176 stated he later asked for the urinal and Staff Member A took the urinal and forcefully slammed it into his groin area over and over an unknown amount of times. Resident #176 stated he felt unsafe around Staff Member A so he reported the incident to the nurse. Resident #176 was asked about his statement in the follow up interview. Resident #176 denied he made the statement that he felt safe in the facility and denied he stated the abuse did not happen. He stated the facility was sweeping things under the rug. Resident #176 stated he currently was not comfortable about his safety at all in the facility. Resident #176 stated regarding his denial the abuse happened, I'm not stupid and I never said that. I am afraid of retaliation in here. Resident #176 stated he was currently concerned about retaliation for talking to the state and worried he will be starved out, for talking to state surveyors. When asked to clarify, he stated he was not afraid of physical abuse but worried about things staff control, such as his medications being late, his call light not being answered, and not getting food served to him. Resident#176 was tearful during the interview and when describing the allegation he hung his head down and was tearful. On 3/5/20 at 10:08 AM, Resident #176 called a family friend in the surveyor's presence and asked the surveyor to listen to the call. Resident #176 asked the family friend if she remembered the interview about the allegation and she stated yes. She then stated she was with Resident #176 during the staff interview for the Incident and Accident follow up report and Resident #176 never stated during the interview he felt safe in the facility and denied any abuse. She stated she did not remember the facility staff asking those questions in her presence. On 3/5/20 at 10:35 AM, the Administrator was interviewed about the Incident and Accident report regarding Resident #176. She stated the person who conducted the Incident and Accident investigation on Resident #176 no longer worked at the facility.

Based on staff and physician interview, policy review, review of Incident and Accident Reports, and record review, it was determined the facility failed to ensure the physician was notified in a timely manner of a resident's accident which resulted in a leg injury. This was true for 1 of 8 residents (Resident #239) whose records were reviewed. This failed practice resulted in a lack of information being provided to the physician on which to base treatment decisions, causing harm to Resident #239 due to a 9 day delay in sufficient treatment for [REDACTED]. Resident #239 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 2/18/19, documented Resident #239 had a severe cognitive impairment and sometimes understood others and was understood. The MDS assessment documented Resident #239 required extensive assistance of two staff members with bed mobility, transfers, dressing, and hygiene. The MDS documented she was dependent on two staff members for bathing and toileting. The MDS documented Resident #239 experienced one fall without injury since the prior assessment. A Nurse's Progress Note, dated 4/16/19 at 4:34 PM, documented Resident #239's son reported a possible injury that occurred on 4/7/19 while he was with Resident #239. The note documented Resident #239's son reported the injury on 4/7/19 to the floor nurse. The note documented Resident #239's right lower extremity was dragging on the ground and bent backwards under her wheelchair. The note documented Resident #239 cried out, Ouch! at the time of the incident. The Facility's Accidents and Incidents: Report, Investigate, Review and Analysis policy, dated (MONTH) (YEAR), defined an accident as Any unexpected or unintentional incident that resulted in injury or illness. The policy documented steps to be taken which included the following: * Instruct staff, resident/resident representative, family, visitor, etc. to report immediately, without fear of reprisal, any accident/incident. * Complete an electronic accident/incident report. The policy stated the electronic accident/incident report was to be initiated .immediately upon identification of an accident/incident . A 4/7/19 accident/incident report could not be found which should have documented Resident #239's right leg injury. There was no documentation found the physician was notified of the injury. On 5/8/19 at 9:47 AM, RN #1 stated she first learned about the possible injury during a care conference with Resident #239's son and daughter on 4/16/19. RN #1 stated during the care conference, Resident #239's son stated on 4/7/19 when he assisted his mother by pushing her wheelchair, her right leg was dragging on the ground and was caught twisted or bent backwards under her wheelchair. RN #1 stated Resident #239's son stated he heard a loud popping sound and Resident #239 cried out, Ouch!. RN #1 stated Resident #239's son reported the injury to LPN #3 when he brought Resident #239 back to the facility on [DATE]. RN #1 stated LPN #3, who was notified on 4/7/19 by the son, should have notified the physician. The facility's (MONTH) (YEAR) Accidents and Incidents: Report, Investigate, Review and Analysis policy did not include information related to floor staff reporting directly to the physician. The procedure stated, Report all accident/incidents to the Executive Director. The policy stated injuries involving a medical device were to be immediately reported to the Executive Director and allegations of abuse, neglect, mistreatment, injuries of unknown source, and misappropriation were to be immediately reported to the Executive Director and the DON/designee. Timeframes for reporting other types of accidents and incidents was not included in the policy. The facility failed to ensure policies and procedures were developed, implemented, and monitored necessary to ensure Resident #239's accident and resulting right leg injury, which had the potential to require physician intervention, was immediately reported to the physician. On 5/8/19 at 11:20 AM, the DON and the Administrator stated Resident #239's son reported an injury to LPN #3 on 4/7/19 and she (LPN #3) assessed the injury and felt it was not far from Resident #239's baseline. The Administrator stated Resident #239 normally had swelling to her right knee from a history [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus - a bacterial infection) and a knee replacement. The DON stated the facility received a phone call on 4/9/19 from Resident #239's daughter requesting additional pain medications and to ensure the facility knew about the swelling to her right knee. A faxed Physician Notification, dated 4/9/19 at 7:00 PM, documented Resident #239's daughter called and was worried about Resident #239's knee pain. With recent weight loss her knee brace does (not) (sic) fit anymore. The fax documented the daughter made an appointment with an orthopedic physician for a new brace. The fax documented Resident #239's daughter was worried about increased pain and if Resident #239's scheduled Tylenol could be increased from twice a day to three times a day just temporarily until she gets a new brace? The Physician Notification did not include information related to the accident and resulting right leg injury reported by Resident #239's son on 4/7/19. A handwritten note on the top of the 4/9/19 Physician Notification stated 4/10/19 Forward to (physician's name) to address. A handwritten note at the bottom of the form documented Tylenol 500 mg po TID (D/C current Tylenol BID). On 5/9/19 at 11:46 AM, the physician stated she received a notification by fax from the facility regarding Resident #239's pain issue and need for additional medications. She stated the facility may have sent it on 4/9/19. However, when the information was faxed she likely did not see the notification right away. The physician stated she received multiple faxes on a daily basis. The physician stated if the fax was documented with her signature on 4/11/19 she most likely did not receive the fax right away. The physician stated she did not recall receiving another notification regarding what happened to Resident #239's right leg. She stated she may have received another fax and it was easiest to call her to get a hold of her immediately. The facility failed to ensure the physician was provided with complete information on which to base treatment decisions and the physician was contacted in a manner which allowed for more timely care to be provided. A Nurse's Progress Note, dated 4/11/19 at 8:23 PM, documented Resident #239's daughter called the facility to see if LPN #4 knew about Resident #239's swollen right leg. The note documented LPN #4 did not know about the injury and she was going to assess Resident #239's leg. The note documented Resident #239's right knee appears 2x (two times) larger than the other knee. The note documented an ice pack was placed and helped decrease the swelling. The note documented another staff member was aware of the injury to Resident #239's right knee when it was reported by Resident #239's son on Sunday (4/7/19), that her right knee might have bent too far back and was stuck under her wheelchair. The note documented Resident #239's son spoke with the evening shift nurse about the injury on 4/7/19. The note documented the physician was notified about the knee swelling. A faxed Physician Notification, dated 4/11/19 at 9:24 PM, documented Resident #239's right knee was swollen with no signs and symptoms of pain. The fax documented ice was applied to her knee which was effective in decreasing the swelling. The fax documented .after speaking with staff and residents (sic) son it appeared that her swelling was due to a transfer on Sunday (4/7/19) by her son when she was out with him . The fax documented Resident #239 was placed on alert charting and staff were going to monitor her for pain and swelling in her right knee. The notification to the physician did not include complete information regarding Resident #239's leg being caught under her wheelchair and bending too far back as documented in the 4/11/19 Nurse's Progress Note. During an interview with the DON and the Administrator, on 5/8/19 at 11:20 AM, the DON stated after the physician's notification note and the previous note written by LPN #4 on 4/11/19 were read to her, the notes did not contain the same information regarding the incident. The facility failed to ensure the physician was provided with complete information on which to base treatment decisions. The physician responded to the faxed notification on 4/12/19 at an unknown time. The physician documented agreement with the actions that the LPN had taken and documented Elevate as much as possible. Notify MD if not improving. The facility noted the order on 4/12/19 and input the order on 4/13/19. Resident #239's Physician order [REDACTED]. Nursing Progress Notes, dated 4/12/19 at 1:56 AM and at 11:25 PM, 4/13/19 at 11:43 PM, 4/15/19 at 2:50 PM, and 4/16/19 at 2:05 AM, documented Resident #239's right knee was swollen. There was no documentation the physician was notified of the continued swelling to the right knee on 4/13/19 and 4/15/19. An Incident and Accident report, dated 4/16/19 at 3:26 PM and revised on 4/21/19 at 9:21 PM, documented the physician was notified of Resident #239's injury at 4:00 PM on 4/16/19, 9 days after the injury occurred. On 5/8/19 at 9:47 AM, RN #1 stated when she first learned about the possible injury during a care conference with Resident #239's son and daughter on 4/16/19, she immediately evaluated Resident #239's right knee and found a large 36 cm by 9 cm yellow faded bruise extending from her right upper thigh to the lower portion of her shin and she notified the physician of what happened. On 4/17/19, an x-ray order was received and a subsequent Radiology Report, dated 4/17/19, documented there was an acute fracture to Resident #239's right distal femur (thigh bone). The facility failed to ensure the physician was provided with timely, comprehensive information regarding the circumstances under which Resident #239's right leg injury occurred. This failed practice resulted in a lack of information being provided to the physician on which to base treatment decisions for a period of 9 days.

Based on staff interview, record review, review of Incident and Accident Reports, and policy review, it was determined the facility failed to ensure professional standards of nursing practice were followed for 1 of 4 residents (Resident #239) who was reviewed for nursing standards of practice. The failed practice resulted in harm to Resident #239 when she sustained a femur (thigh bone) fracture, resulting in increased swelling and pain, which was not recognized and treated for [REDACTED]. The facility's Accidents and Incidents: Report, Investigate, Review and Analysis policy, dated (MONTH) (YEAR), defined an accident as any unexpected or unintentional incident that resulted in injury. The procedure outlined the following steps when an incident occurred: * Staff, residents, residents' families, and visitors report any accidents/incidents immediately. * Facility staff were to complete an electronic incident and accident report. * Protect the resident from further harm. * Staff were to complete a physical assessment related to the incident. * Staff were to initiate an Incident and Accident Report immediately upon knowledge of the incident to include falls, skin issues, alleged abuse, and injuries of unknown origin. * Staff were to complete, review, and submit the Incident and Accident Report. * Staff were to report the incident and accident to the Administrator. * Staff were to document in the resident's chart for 72 hours following the incident and accident (alert charting). This policy was not followed. Resident #239 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #239's care plan included areas for limited physical mobility related to [MEDICAL CONDITION], revised on 9/13/17, and acute pain, revised on 8/28/18. Interventions for her limited physical mobility included the assistance of two staff and monitoring/documentation/reporting to the physician, as needed, signs and symptoms of immobility and fall related injury. Interventions for acute pain included to complete a pain assessment for new complaints of pain, upon changes in condition, and as needed. The ADL section of the care plan initiated 11/10/17 and revised on 2/11/19, instructed staff to use a mechanical aid, Sit to Stand and 2 staff for transfers. A physician visit report, dated 1/24/19, stated Resident #239 was non-verbal and it was difficult to interpret her response to questions asked by the physician. The physician documented Resident #239 .shakes her head side to side to all answers. A subsequent physician visit report, dated 3/21/19, stated Resident #239 was non-verbal and had minimal interactions. A quarterly MDS assessment, dated 2/18/19, documented Resident #239 had severe cognitive impairment and sometimes understood others and was sometimes understood, and her speech was unclear with slurred or mumbled words. The MDS assessment documented Resident #239 required extensive assistance of two staff with bed mobility, transfers, dressing, and hygiene. The MDS also documented she was dependent on two staff for bathing and toileting. The MDS documented Resident #239 experienced one fall without injury since the prior assessment. A Physical Therapy Evaluation and Plan of Treatment, dated 2/6/19, documented Resident #239's was referred to physical therapy for a fall from her wheelchair when bending to pick up an item. The short-term goal was to demonstrate an improved sitting position in her wheelchair to reduce fall risk and allow for improved functional mobility. The long-term goal was for Resident #239 to maintain an upright position with a wedge seat in the wheelchair allowing her to tolerate being in the wheelchair for long periods and perform short distances of self-propulsion without an increased risk for falling. A Physical Therapy progress note, dated 3/21/19, documented Resident #239 demonstrated improved postural alignment with a new Vicair cushion (a cushion which provides support and pressure distribution) which was modified to simulate a wedge cushion, with fewer air pockets in the back and more in the front. The progress note documented Resident #239 was able to self-propel for short distances using her legs. Resident #239's Physical Therapy Discharge Summary, dated 3/26/19, documented she could move her wheelchair using both legs. The discharge recommendations requested staff to continue to monitor Resident #239's alignment with her new wheelchair cushion. Progress notes for Resident #239 included documentation she experienced an injury to her leg involving her wheelchair on 4/7/19. The progress notes were documented as follows: A Nurse's Progress Note signed by LPN #4, dated 4/11/19 at 8:23 PM, stated Resident #239's daughter called and asked if nursing staff were aware of her swollen leg. LPN #4 documented she told Resident #239's daughter nursing staff did not know about the swelling to her leg and she was going to assess her. LPN #4 documented Resident #239's right knee had swelling and appeared .2x larger then (sic) the other knee. LPN #4 documented she placed an ice pack on the right knee. LPN #4 documented other staff were aware of the swelling to Resident #239's right knee because it was reported on Sunday 4/7/19, 4 days earlier. LPN #4 documented she contacted Resident #239's son via phone and he informed her on Sunday, 4/7/19, he was attempting to transfer Resident #239 and .her knee might have got bent to (sic) far and got stuck under her w/c (wheelchair). Resident #239's son told LPN #4 he had talked to the nurse on the evening shift on 4/7/19, about her knee. LPN #4 documented she was going to let the physician know about the swelling to the right knee and the DON was notified. Resident #239's record did not include a progress note from nursing staff regarding the conversation with her son on 4/7/19. There was no documentation in Resident #239's Nurse's Progress Notes from 4/7/19 through 4/10/19 related to assessment and monitoring of Resident #239's pain level or knee following a reported injury on 4/7/19. The family asked on 4/11/19, if staff were aware of the resident 239's right knee injury with increased swelling and pain. The documented response on 4/11/19 at 8:23 PM in a nursing progress note was no. The care plan instructed staff to assess pain using the Wong Baker pain scale. The scale shows a series of faces ranging from a happy face at 0, or no hurt, to a crying face at 10, which represents hurts like the worst pain imaginable. This scale requires the resident to select the face which best represent the level of pain they are experiencing. The quarterly MDS dated [DATE], documented Resident #239 had severe cognitive impairment and sometimes understood others and was sometimes understood, and her speech was unclear with slurred or mumbled words. Additionally, the physician visit report, dated 1/24/19, stated Resident #239 was non-verbal and it was difficult to interpret her response to questions asked by the physician. The physician documented Resident #239 .shakes her head side to side to all answers. There was no documentation of Resident #239's pain level using the Wong Baker pain scale faces, in the progress notes or TAR, or other documentation describing how staff determined Resident #239, with increased swelling due to a leg injury, was or was not in pain. Subsequent Nurse's Progress Notes documented Resident #239's right knee was swollen on 4/12/19 at 1:56 AM and 11:25 PM, 4/13/19 at 11:43 PM, and 4/16/19 at 2:05 AM. There was no documentation in the progress notes, dated 4/12/19 to 4/15/19, a physician was notified of the continued swelling to Resident #239's right knee. A Nurse's Progress Note signed by RN #1, dated 4/16/19 at 4:34 PM, documented Resident #239's son reported a possible injury that occurred on 4/7/19, while he was helping her. The note stated per Resident #239's son her right foot was dragging on the ground and bent backwards under her wheelchair. The note documented Resident #239's son stated she cried out Ouch!' at the time of the incident. RN #1 documented she assisted Resident #239 into bed to have her adult brief changed and RN #1 assessed her right knee due to the recent swelling and notification of the incident that day. RN #1 documented Resident #239 had swelling to her right knee and Tenderness noted upon movement of right leg. The note also documented Resident #239's right leg had a yellow, faded bruise extending from her right upper thigh to the lower portion of her shin and the bruise was approximately 36 cm by 9 cm (14.5 inches by 3.5 inches). Resident #239's record did not include documentation of a bruise to her right leg prior to the 4/16/19 Nurse's Progress Note. Resident #239's record included Physician Notifications, which were faxed on 4/9/19 and 4/11/19, and written as follows: - A Physician Notification, dated 4/9/19 at 7:00 PM, documented Resident #239's daughter called and was worried about her knee pain. The fax documented Resident #239's daughter made an appointment with an orthopedic physician for a new brace because she believed the current one did not fit well anymore. The fax documented Resident #239's daughter requested her scheduled Tylenol be increased from twice a day to three times a day. The physician responded on 4/11/19, two days later, to the request and included an order to increase Tylenol to 500 mg three times a day. There were no Nurse's Progress Notes in Resident #239's record which included documentation of the phone call from her daughter or the contact with the physician about knee pain. - A Physician Notification, dated 4/11/19 at 9:24 PM, stated Resident #239 had swelling to her right knee with no signs and symptoms of pain. The fax stated ice was applied to her knee and the knee was elevated in her wheelchair, which was effective in decreasing the swelling. The fax stated Resident #239's son reported the swelling .was due to a transfer on Sunday (4/7/19) by her son when she was out with him. The fax stated Resident #239 was placed on alert charting to monitor for pain and swelling and to Please advise. The notification to the physician did not include a description from the son that Resident #239's leg was caught under her wheelchair and was bent back. The physician responded to the faxed notification the following day on 4/12/19, which documented Agree (with) above and to elevate the right knee as much as possible, and to notify the physician if the knee was not improving. A care conference was held 9 days after facility staff were notified by family of the potential injury to Resident #239's right leg. The Care Conference Note, dated 4/16/19 at 3:30 PM, documented Resident #239, her children, a social service assistant, and RN #1 were in attendance. The note stated topics discussed were Resident #239's plan of care, recent medication/order changes, upcoming appointments, and recent weights. The note stated the family reported at the conference Resident #239's .leg getting caught under her wheelchair while son was assisting her around building two weekends previous. The Care Conference Note stated RN #1 was going to request an x-ray for the right knee prior to her orthopedic appointment which was scheduled on 5/6/19. Resident #239's ADL reports for 3/1/19 through 4/17/19, documented her skin was assessed by CNAs every shift. The CNAs were to document yes if the resident had new skin impairments or no if new skin impairments were not identified. Resident #239's ADL reports documented no for all shifts from 3/1/19 through 4/17/19. Resident #239's 36 cm by 9 cm bruise to her right leg was identified by nursing staff on 4/16/19. The CNA's documentation of no new skin impairments was inconsistent with the discovery of the bruise on her right leg on 4/16/19. A verbal Physician Order, dated 4/17/19 at 12:57 PM, documented the facility requested a stat (urgent/rush) x-ray for Resident #239's right thigh, right knee, and right shin. A Nurse's Progress Note, dated 4/17/19 at 4:00 PM, documented Resident #239 was awaiting a stat mobile x-ray of her right leg, 3 hours after the stat order was received. At 9:17 PM on 4/17/19, a Nurse's Progress Note stated a physician order [REDACTED].#239 to the local emergency department for evaluation and treatment of [REDACTED]. Resident #239 was transported via ambulance to the hospital and was accompanied by her son. A Radiology Report signed by a radiologist on 4/17/19 at 7:11 PM, documented Resident #239 had a fracture to her right femur. The x-ray was ordered and completed 10 days following the initial report of the incident by Resident #239's son to facility staff on 4/7/19. The incident with Resident #239's right leg was not documented in an Incident and Accident Report prior to 4/16/19, 9 days after her son informed facility nursing staff of the injury. An Incident and Accident Report, dated 4/16/19 at 3:26 PM, documented during the care conference Resident #239's son stated on 4/7/19, her right foot dragged on the ground and bent backwards while he was pushing her wheelchair. The report documented Resident #239 said, Ouch! at the time of the incident. The report documented a faded yellow bruise which measured 36 cm by 9 cm was identified on Resident #239's right leg. The Incident and Accident Report stated the physician was called and informed about the incident and the bruise and monitoring of the bruise was started and added to the TAR, adjustable foot and leg rests were placed on Resident #239's wheelchair, and her care plan was updated. A follow-up note on the Incident and Accident Report, dated 4/19/19, documented on 4/17/19 an order was received for a stat x-ray of Resident #239's right thigh, knee, and shin. The note stated the x-ray showed a [MEDICAL CONDITION] femur and the physician was notified of Resident #239's fractured femur and she was transferred to the hospital for further evaluation and treatment. The follow-up note further documented Resident #239 was transferred from the local hospital to another hospital out of state for further treatment of [REDACTED]. A subsequent follow-up note to the Incident and Accident report, dated 4/21/19, documented LPN #3, who received the injury report from the son on 4/7/19, stated she assessed Resident #239 on that day and her right leg appeared swollen but not different from its normal appearance. The report documented Resident #239 had a right knee arthroplasty (knee replacement) and utilized a knee brace constantly. The report documented Resident #239's right knee brace was loose fitting due to weight loss and nursing staff did not believe the swelling to the right knee was due to an injury but related to the brace not fitting properly. The report documented Resident #239 did not appear to have increased pain and she was successfully medicated for pain. The Incident and Accident Report, dated 4/16/19 at 3:26 PM, included a section for witness statements. This section included statements from Resident #239's son, LPN #3, CNA #6, CNA #7, and CNA #8. The statements from staff were documented as follows: - CNA #6 stated The bruise first showed up on 04/08/19, the day after the incident with her son. - LPN #3 stated Resident #239's son told her that he either bumped her leg, or her leg did not lift while he was pushing her in the wheelchair and Resident #239 yelled out Ouch when it happened. LPN #3 stated she looked at the right knee and there was swelling but no warmth, redness, or bruising and Resident #239 did not complain of pain. - CNA #7 stated During the time resident was having knee swelling she did not seem to be having any pain during transfers. She seemed like her normal self. - CNA #8 stated When resident had her knee swelling, she did seem like she was in more pain. We reported this to the nurse when she complained of pain. On 5/8/19 at 8:48 AM, CNA #1 stated approximately three weeks prior to Resident #239 leaving the facility she recalled Resident #239's leg was dragging on the ground more and she required a foot rest on her wheelchair at times. On 5/8/19 at 9:14 AM, CNA #3 stated she filled out a witness statement for Resident #239's injury a week after she was discharged from the facility. CNA #3 stated she did not have many contacts with Resident #239 and did not know how she fractured her leg. On 5/8/19 at 9:29 AM, LPN #1 stated she was not working when Resident #239's injury was first reported by the son. LPN #1 stated it was reported to her the son heard a loud popping sound and Resident #239 cried out, Ouch! LPN #1 stated she was monitoring the swelling, utilizing ice packs, and elevating her leg to assist with decreasing the swelling. LPN #1 stated she began monitoring the bruise prior to Resident #239 leaving the facility and a fractured femur was discovered. LPN #1 stated she did not recall Resident #239 appearing to be in more pain. LPN #1 stated the daughter asked for increased pain medications for Resident #239's knee. On 5/8/19 beginning at 9:47 AM, RN #1 stated she first learned about the possible injury during a care conference with the son and daughter on 4/16/19. RN #1 stated during the care conference the son stated on 4/7/19, when he assisted his mother by pushing her wheelchair, her right leg was dragging on the ground and was caught twisted or bent backwards under her wheelchair. RN #1 stated the son stated he heard a loud popping sound and Resident #239 cried out, Ouch!. RN #1 stated the son reported the injury to LPN #3 when he brought Resident #239 back to the facility the same day. RN #1 stated, on 4/16/19, she immediately evaluated Resident #239's right knee and found a large 36 cm by 9 cm yellow faded bruise extending from her right upper thigh to her shin. RN #1 stated Resident #239's knee was swollen as well. RN #1 stated she called the physician to obtain an x-ray of the right leg. RN #1 stated she was unsure when the bruise was sustained and the bruise came out of nowhere on either 4/16/19 or 4/17/19. RN #1 stated a faded bruise was indicative of an older injury and she was unsure how the staff did not identify the bruise sooner than 4/16/19, and why staff documented there were no skin impairments on the skin assessments. During the same interview RN #1 stated she then initiated an Incident and Accident investigation on 4/16/19, and through the findings she stated LPN #3, who evaluated Resident #239's leg on 4/7/19, did not note any bruising or increased pain. LPN #3 did note swelling to her right knee with the brace in place. RN #1 stated LPN # 3 did not complete an incident report, initiate alert charting, or notify the RCM, the DON, or the physician. RN #1 stated the family called the facility a couple of times to discuss the increased pain and swelling to the right knee. RN #1 stated after one of the phone calls, on 4/11/19, Resident #239 was placed on alert charting for the injury. RN #1 stated LPN #4 did not initiate an incident report on 4/11/19. RN #1 stated the nurses on 4/7/19 and 4/11/19 both should have initiated an investigation into Resident #239's leg injury. RN #1 stated she obtained four staff members witness statements about the incident that occurred with Resident #239 on 4/7/19, beginning on 4/16/19 and ending on 4/21/19. RN #1 stated she obtained these interviews per direction from the DON. RN #1 stated on 4/25/19, the facility was notified by a hospital that Resident #239 had a fractured humerus (long bone in the upper arm) in addition to the femur fracture. RN #1 stated when the facility was notified of the humerus fracture, she then obtained witness statements from 54 staff members in the building regarding the incident on 4/7/19. Answers to the Witness Statements documented one staff member heard Resident #239 fell prior to discharge from the facility, two staff members identified a bruise on her right leg, four staff members documented concerns with increased pain, one staff member identified an issue with transferring Resident #239, eight staff members heard about an incident involving the family and her right leg, and one staff member documented an increased need for assistance with dressing and transfers. A Witness Statement, dated 4/24/19, documented CNA #6 who identified the bruise on 4/8/19, documented he did not recall the exact date he saw the bruise to her right leg. The statement documented Resident #239's right leg had slight discoloration directly at the swelling sight and at the knee on 4/8/19, and the large bruise down her thigh and shin did not appear until closer to 4/15/19. A Witness Statement, dated 5/3/19, from CNA #5 who provided a shower to Resident #239 on 4/7/19, following the outing with her son, documented the son stated Resident #239's leg was caught deep under her wheelchair. The statement documented the son reported Resident #239's right leg needed to be assessed and CNA #5 stated I could tell something was very wrong. Her leg looked broken or dislocated at the knee. CNA #5 stated she informed LPN #3 right away asking for her to look at Resident #239 in the shower room. The statement documented when CNA #5 and another CNA later laid Resident #239 down in bed her leg did not lay flat on the bed. CNA #5 stated she asked LPN #3 to assess Resident #239's right leg again, which she did. An untitled document, dated 5/4/19, documented an unknown staff member met with CNA #5 to discuss Resident #239's incident on 4/7/19. The document stated CNA #5 related what happened to Resident #239's leg from speaking with the son and she alerted LPN #3 twice of an issue with Resident #239's leg. The document stated LPN #3 assessed Resident #239 both times. The document stated CNA #5 did not complete a Stop and Watch (A report used to identify concerns for residents) or document the concerns on her shower sheet. The document stated CNA #5 thought LPN #3 would address the concerns in her notes. On 5/8/19 at 11:20 AM, the DON and the Administrator stated Resident #239's son reported an injury to LPN #3 on 4/7/19, and she assessed the injury and felt it was not far from Resident #239's baseline status. The DON stated the facility received a phone call on 4/9/19, from Resident #239's daughter requesting additional pain medications and to ensure the facility knew about the swelling to her right knee. The DON stated on 4/11/19, the daughter called again to ensure the staff were aware of Resident #239's right knee injury. The Administrator stated Resident #239 normally had swelling to her right knee from a history [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus - a bacterial infection) and a knee replacement. The DON stated the facility educated LPN #3, the nurse Resident #239's son the reported the injury to on 4/7/19. The education included the need to complete an investigation, write a brief note, and place the resident on alert charting for injury monitoring. The DON stated she was not aware the physician was provided minimal information regarding what happened to Resident #239's right leg as reported by her son. The DON stated she was unaware how staff could not see a large bruise on her right leg when completing skin assessments every shift between 4/7/19 through 4/17/19. The DON stated she was not made aware of the extent of the injury to Resident #239's right leg until 4/16/19. The DON stated on 4/11/19, LPN #4 told her Resident #239's right leg brace was ill fitting and the family had made an appointment to address the concern. After the physician notification fax and the progress note written by LPN #4 were read to the DON, she stated they did not include the same information. The DON stated based on LPN #4's progress note she would have completed an Incident and Accident Report and an investigation. The DON stated the facility had a process to identify concerns that need investigation through a daily review of all residents' alert charting notes. The DON stated this process was not completed. On 5/8/19 at 3:40 PM, the DON and the Administrator stated through examination of Resident #239's first investigation into the injury, the facility identified a lack of thoroughness. The DON stated RN #1 was new to her position and was learning the correct procedures. On 5/9/19 at 11:46 AM, the physician stated she received a notification by fax from the facility regarding Resident #239's pain issue and need for additional medications. She stated the facility may have sent it on 4/9/19. However, when the information was faxed she likely did not see the notification right away. The physician stated she received multiple faxes on a daily basis. The physician stated if the fax was documented with her signature on 4/11/19 she most likely did not receive the fax right away. The physician stated she did not recall receiving another notification regarding what happened to Resident #239's right leg. She stated she may have received another fax and it was easiest to call her to contact her immediately. Professional standards of nursing practice were not followed when the facility failed to: * Ensure nursing staff followed the facility's policy for reporting and investigating accidents when Resident #239's son reported and described her leg injury to nursing staff. * Ensure nursing staff responsible for Resident #239's care and accident investigations were competent to do so. * Ensure Resident #239's pain level was effectively assessed using a process consistent with her impaired cognition and limited communication abilities. * Ensure staff responded correctly to Resident #239's injury by identifying and assessing her leg injury and immediately reporting the increased swelling and bruising to her physician. * Ensure effective communication among staff regarding the full-extent of Resident #239's accident/leg injury as reported by her son.

Based on staff interview, I&A report review, policy review, and record review, it was determined the facility failed to ensure residents were not subjected to verbal and physical abuse by staff. This was true for 1 of 1 resident (Resident #27) who was reviewed for abuse/neglect. This resulted in harm to Resident #27 when he experienced verbal and physical abuse by a staff member during cares. Findings include: The facility's Abuse policy, dated (MONTH) (YEAR), documented residents had the right to be free from abuse and neglect. The policy documented staff members would not verbally or physically abuse residents. The policy documented any allegation of abuse or neglect should be reported immediately. The policy documented verbal abuse included using disparaging and derogatory terms towards residents and physical abuse included being rough with residents. The policy documented staff members were instructed to report all incidents of abuse immediately to the Executive Director, without fear of retribution. Resident #27 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 12/1/18, documented Resident #27 had severe cognitive impairment with no behavioral disturbances and required extensive assistance of two staff members with transfers, bed mobility, and toileting. The ADL care plan, dated 9/10/18, documented Resident #27 required two person staff assistance with toilet use, transfers, and bed mobility. The care plan documented staff were to utilize a mechanical lift for transfers. An I&A Report, dated 12/16/18, documented Resident #27 sustained two skin tears of unknown source, one on the top his right hand between the 1st and 2nd fingers by the knuckles and one at the base of his thumb. The report documented Resident #27 was self-propelling his wheelchair in the lobby and his hand was bleeding. The report documented Resident #27 had confusion and impaired memory and no witnesses were found. The IDT follow-up note for the 12/16/18 skin tears, dated 12/26/18 (10 days later), documented Resident #27 was transferred incorrectly and sustained two skin tears. The report documented Resident #27 was transferred by a CNA lifting him up and placing him in his wheelchair. (Resident #27) was not transferred by the mechanical lift like he should have been. The follow-up note documented abuse was substantiated, and CNA #1's employment was terminated. An I&A Report, dated 12/20/18, documented, it was discovered that a Staff member has caused multiple skin tears to various residents (this Resident included) from being rough during cares. CNA #2 witnessed CNA #1 yelling, [***] you! [***] you! [***] you! in Resident #27's face because he had a bowel movement at the change of shift. The report also documented Resident #27 sustained a skin tear to his front left forearm. The report did not document the size or extent of the skin tear. The report documented Resident #27 was unable to recall the incident. On 1/10/19 at 11:29 AM, the Acting DNS stated CNA #2 witnessed CNA #1 verbally abuse Resident #27 on 12/20/18, but CNA #2 did not report the incident to the Acting DNS or the Administrator Designee until 12/21/18. The Acting DNS stated CNA #2 was afraid of CNA #1 and did not want to report him for fear of retaliation by CNA #1. The Acting DNS stated although CNA #2 did not report the abuse until 12/21/18, he back dated the I&A report to 12/20/18, to reflect the date the abuse occurred. The IDT follow-up note for the 12/20/18 verbal abuse and skin tear to the left forearm incident, dated 12/26/18, also included documentation of Resident #27's two skin tears which were identified on 12/16/18 and it was discovered that the cause of the skin tears were from CNA #1 handling Resident #27 roughly. The follow up documented CNA #1 was also accused of swearing profanity in Resident #27's face and transferred him incorrectly and sustained two skin tears on 12/16/18. The report documented Resident #27 was transferred by CNA #1 by lifting him up and placing him in his wheelchair. Resident #27 was not lifted by the mechanical lift like he should have been. The report documented CNA #1's employment was terminated for verbal and physical abuse. On 1/7/19 at 2:00 PM, the Acting DNS and the Administrator Designee stated CNA #2 was not comfortable reporting the witnessed abuse to the charge nurse at the time of the 12/20/18 incident while CNA #1 was in the building. The Acting DNS stated the facility educated CNA #2 on reporting allegations of abuse immediately, however, they did not document the education provided to CNA #2. The Administrator Designee stated the facility's I&A reports were incomplete. The Acting DNS stated the facility should have completed and documented witness statements from staff and residents. The Administrator Designee stated the investigation should have included documentation of the education provided to CNA #2 about reporting allegations of abuse immediately. The Administrator Designee stated the investigative process was not followed for the I&As dated 12/16/18 and 12/20/18.

Based on staff interview, I&A report review, policy review, and record review, it was determined the facility failed to ensure residents were not subjected to verbal and physical abuse by staff. This was true for 1 of 1 resident (Resident #27) who was reviewed for abuse/neglect. This resulted in harm to Resident #27 when he experienced verbal and physical abuse by a staff member during cares. Findings include: The facility's Abuse policy, dated (MONTH) (YEAR), documented residents had the right to be free from abuse and neglect. The policy documented staff members would not verbally or physically abuse residents. The policy documented any allegation of abuse or neglect should be reported immediately. The policy documented verbal abuse included using disparaging and derogatory terms towards residents and physical abuse included being rough with residents. The policy documented staff members were instructed to report all incidents of abuse immediately to the Executive Director, without fear of retribution. Resident #27 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 12/1/18, documented Resident #27 had severe cognitive impairment with no behavioral disturbances and required extensive assistance of two staff members with transfers, bed mobility, and toileting. The ADL care plan, dated 9/10/18, documented Resident #27 required two person staff assistance with toilet use, transfers, and bed mobility. The care plan documented staff were to utilize a mechanical lift for transfers. An I&A Report, dated 12/16/18, documented Resident #27 sustained two skin tears of unknown source, one on the top his right hand between the 1st and 2nd fingers by the knuckles and one at the base of his thumb. The report documented Resident #27 was self-propelling his wheelchair in the lobby and his hand was bleeding. The report documented Resident #27 had confusion and impaired memory and no witnesses were found. The IDT follow-up note for the 12/16/18 skin tears, dated 12/26/18 (10 days later), documented Resident #27 was transferred incorrectly and sustained two skin tears. The report documented Resident #27 was transferred by a CNA lifting him up and placing him in his wheelchair. (Resident #27) was not transferred by the mechanical lift like he should have been. The follow-up note documented abuse was substantiated, and CNA #1's employment was terminated. An I&A Report, dated 12/20/18, documented, it was discovered that a Staff member has caused multiple skin tears to various residents (this Resident included) from being rough during cares. CNA #2 witnessed CNA #1 yelling, [***] you! [***] you! [***] you! in Resident #27's face because he had a bowel movement at the change of shift. The report also documented Resident #27 sustained a skin tear to his front left forearm. The report did not document the size or extent of the skin tear. The report documented Resident #27 was unable to recall the incident. On 1/10/19 at 11:29 AM, the Acting DNS stated CNA #2 witnessed CNA #1 verbally abuse Resident #27 on 12/20/18, but CNA #2 did not report the incident to the Acting DNS or the Administrator Designee until 12/21/18. The Acting DNS stated CNA #2 was afraid of CNA #1 and did not want to report him for fear of retaliation by CNA #1. The Acting DNS stated although CNA #2 did not report the abuse until 12/21/18, he back dated the I&A report to 12/20/18, to reflect the date the abuse occurred. The IDT follow-up note for the 12/20/18 verbal abuse and skin tear to the left forearm incident, dated 12/26/18, also included documentation of Resident #27's two skin tears which were identified on 12/16/18 and it was discovered that the cause of the skin tears were from CNA #1 handling Resident #27 roughly. The follow up documented CNA #1 was also accused of swearing profanity in Resident #27's face and transferred him incorrectly and sustained two skin tears on 12/16/18. The report documented Resident #27 was transferred by CNA #1 by lifting him up and placing him in his wheelchair. Resident #27 was not lifted by the mechanical lift like he should have been. The report documented CNA #1's employment was terminated for verbal and physical abuse. On 1/7/19 at 2:00 PM, the Acting DNS and the Administrator Designee stated CNA #2 was not comfortable reporting the witnessed abuse to the charge nurse at the time of the 12/20/18 incident while CNA #1 was in the building. The Acting DNS stated the facility educated CNA #2 on reporting allegations of abuse immediately, however, they did not document the education provided to CNA #2. The Administrator Designee stated the facility's I&A reports were incomplete. The Acting DNS stated the facility should have completed and documented witness statements from staff and residents. The Administrator Designee stated the investigation should have included documentation of the education provided to CNA #2 about reporting allegations of abuse immediately. The Administrator Designee stated the investigative process was not followed for the I&As dated 12/16/18 and 12/20/18.

Based on staff interview, I&A report review, policy review, and record review, it was determined the facility failed to ensure injuries of unknown source and verbal and physical abuse were thoroughly investigated. This was true for 2 of 2 residents (#27 and #225) who were reviewed for abuse/neglect. Resident #27 was harmed when he was verbally and physically abused by a CNA, and Resident #225 had the potential to experience harm from physical, and possible verbal, abuse by a CN[NAME] The deficient practice also placed the other 66 residents residing in the facility who received care from CNA #1 during his employment, at risk of undetected physical and/or verbal abuse. Findings include: The facility's Abuse policy, dated (MONTH) (YEAR), documented residents had the right to be free from abuse and neglect. The policy stated all alleged violations were thoroughly investigated and documents were retained showing all alleged violations were thoroughly investigated. The policy also documented the facility prevented further potential abuse and/or neglect while the investigation was in process. The policy documented verbal abuse included using disparaging and derogatory terms towards residents and physical abuse included being rough with residents. 1. Resident #27 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 12/1/18, documented Resident #27 was severely cognitively impaired with no behavioral disturbances and required extensive assistance of two staff members with transfers, bed mobility, and toileting. The ADL care plan, dated 9/10/18, documented Resident #27 required two-person staff assistance with toilet use, transfers, and bed mobility. The care plan documented staff were to utilize a mechanical lift for transfers. Resident #27 had two incidences which were not thoroughly investigated as follows: a. An I&A Report, dated 12/16/18, documented Resident #27 sustained two skin tears of unknown source, one on the top his right hand between the 1st and 2nd fingers by the knuckles and one at the base of his thumb. The report documented Resident #27 was self-propelling his wheelchair in the lobby and his hand was bleeding. The report documented Resident #27 had confusion and impaired memory and no witnesses were found. There was no documented evidence the facility completed a thorough investigation of Resident #27's 12/16/18 skin tears as potential physical abuse. The investigation did not include an assessment of Resident #27's right hand skin tears, staff or resident interviews to determine the origin of the skin tears, progress notes identifying the progression of the skin tears, and/or witness statements. Resident #27's record did not document implementation of preventative measure to protect him from further injury while the investigation was in progress. The IDT follow-up note for the 12/16/18 skin tears, dated 12/26/18 (10 days later), documented Resident #27 was transferred incorrectly and sustained two skin tears. The report documented Resident #27 was transferred by a CNA lifting him up and placing him in his wheelchair. He was not lifted in the mechanical lift like he should have been. The follow-up note documented abuse was substantiated, and CNA #1's employment was terminated. b. On 1/10/19 at 11:29 AM, the Acting DNS stated CNA #2 witnessed CNA #1 verbally abusing Resident #27 on 12/20/18, but CNA #2 did not report the incident to the Acting DNS or the Administrator Designee until 12/21/18. The Acting DNS stated CNA #2 was afraid of CNA #1 and did not want to report him for fear of retaliation by CNA #1. The Acting DNS stated an I&A was completed on 12/21/18, however, he back dated the I&A to 12/20/18, to reflect the date the abuse occurred. The I&A Report, dated 12/20/18, documented, it was discovered that a Staff member had caused multiple skin tears to various residents (this Resident included) from being rough during cares. CNA #2 witnessed CNA #1 yelling, [***] you! [***] you! [***] you! in Resident #27's face because he had a bowel movement at the change of shift. The report also documented Resident #27 sustained a skin tear on the front of his left forearm. The report documented Resident #27 was unable to recall the incident. There was no documented evidence the facility completed a thorough investigation of the physical and verbal abuse which occurred on 12/20/18. The physical abuse investigation lacked documentation of the size or extent of the skin tear to Resident #27's left forearm, staff or resident interviews to determine the origin of the skin tear, or progress notes identifying the progression of the skin tear. The verbal abuse investigation did not document potential verbal abuse was ruled out for other residents. The investigation did not include witness statements regarding the physical or verbal abuse. The IDT follow-up note for the 12/20/18 verbal abuse and skin tear to the left forearm, dated 12/26/18, documented Resident #27 sustained two skin tears on 12/16/18 and it was discovered that the cause of the skin tears were from CNA #1 handling Resident #27 roughly. The follow up note documented CNA #1 was also accused of swearing profanities in Resident #27's face and transferred him incorrectly and sustained two skin tears on 12/16/18. The report documented Resident #27 was transferred by CNA #1 lifting him up and placing him in his wheelchair. Resident #27 was not lifted in the mechanical lift like he should have been. The IDT 12/26/18 follow-up note did not document how and when it was determined Resident #27 was incorrectly transferred by CNA #1. The report documented CNA #1's employment was terminated for verbal and physical abuse. On 1/7/19 at 2:00 PM, the Acting DNS and the Administrator Designee stated CNA #2 was not comfortable reporting the witnessed abuse to the charge nurse at the time of the incident while CNA #1 was in the building. The Acting DNS stated the facility educated CNA #2 on reporting allegations of abuse immediately, however, they did not document the education provided to CNA #2. The Administrator Designee stated the facility's I&A reports were incomplete. The Acting DNS stated the facility should have documented witness statements from all staff and residents. The Administrator Designee stated the investigation should include documentation of the education provided to CNA #2 about reporting allegations of abuse immediately. The Administrator Designee stated this process was not completed for the 12/16/18 and 12/20/18 I&A reports. The Administrator Designee stated the facility investigated injuries of unknown source as potential abuse. 2. Resident #225 was admitted to the facility on [DATE], with multiple diagnoses, including dementia. Resident #225 experienced an incident which was not thoroughly investigated as follows: An I&A Report, dated 12/1/18, documented Resident #225 sustained a 2.0 cm by 2.0 cm skin tear to the back of her right calf. The report documented there were no witnesses found. There was no documented evidence the facility completed a thorough investigation of the injury of unknown source which occurred on 12/1/18. The injury of unknown source investigation did not include an assessment of Resident #225's right calf, staff or resident interviews to determine the origin of the skin tears, progress notes identifying the progression of the skin tears, and/or witness statements. Resident #225's record did not document implementation of preventative measure to protect her from further injury. The IDT follow-up note for the 12/1/18 skin tears, dated 12/4/18, documented Resident #225 was transferred with a mechanical lift and the sling was removed forcefully causing a skin tear to the back of her right calf. On 1/10/19 at 11:29 AM, RCM #2 stated Resident #225's skin tear was thought to be caused by CNA #1 when he provided cares roughly. On 1/10/19 at 11:45 AM, the Administrator Designee and the Acting DNS stated CNA #1 was rough during cares with multiple residents and it was determined he physically abused residents. The Administrator Designee stated the facility had not thought to investigate verbal abuse for other residents who received cares from CNA #1 during his employment at the facility.

Based on staff interview, I&A report review, policy review, and record review, it was determined the facility failed to ensure injuries of unknown source and verbal and physical abuse were thoroughly investigated. This was true for 2 of 2 residents (#27 and #225) who were reviewed for abuse/neglect. Resident #27 was harmed when he was verbally and physically abused by a CNA, and Resident #225 had the potential to experience harm from physical, and possible verbal, abuse by a CNA. The deficient practice also placed the other 66 residents residing in the facility who received care from CNA #1 during his employment, at risk of undetected physical and/or verbal abuse. Findings include: The facility's Abuse policy, dated (MONTH) (YEAR), documented residents had the right to be free from abuse and neglect. The policy stated all alleged violations were thoroughly investigated and documents were retained showing all alleged violations were thoroughly investigated. The policy also documented the facility prevented further potential abuse and/or neglect while the investigation was in process. The policy documented verbal abuse included using disparaging and derogatory terms towards residents and physical abuse included being rough with residents. 1. Resident #27 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 12/1/18, documented Resident #27 was severely cognitively impaired with no behavioral disturbances and required extensive assistance of two staff members with transfers, bed mobility, and toileting. The ADL care plan, dated 9/10/18, documented Resident #27 required two-person staff assistance with toilet use, transfers, and bed mobility. The care plan documented staff were to utilize a mechanical lift for transfers. Resident #27 had two incidences which were not thoroughly investigated as follows: a. An I&A Report, dated 12/16/18, documented Resident #27 sustained two skin tears of unknown source, one on the top his right hand between the 1st and 2nd fingers by the knuckles and one at the base of his thumb. The report documented Resident #27 was self-propelling his wheelchair in the lobby and his hand was bleeding. The report documented Resident #27 had confusion and impaired memory and no witnesses were found. There was no documented evidence the facility completed a thorough investigation of Resident #27's 12/16/18 skin tears as potential physical abuse. The investigation did not include an assessment of Resident #27's right hand skin tears, staff or resident interviews to determine the origin of the skin tears, progress notes identifying the progression of the skin tears, and/or witness statements. Resident #27's record did not document implementation of preventative measure to protect him from further injury while the investigation was in progress. The IDT follow-up note for the 12/16/18 skin tears, dated 12/26/18 (10 days later), documented Resident #27 was transferred incorrectly and sustained two skin tears. The report documented Resident #27 was transferred by a CNA lifting him up and placing him in his wheelchair. He was not lifted in the mechanical lift like he should have been. The follow-up note documented abuse was substantiated, and CNA #1's employment was terminated. b. On 1/10/19 at 11:29 AM, the Acting DNS stated CNA #2 witnessed CNA #1 verbally abusing Resident #27 on 12/20/18, but CNA #2 did not report the incident to the Acting DNS or the Administrator Designee until 12/21/18. The Acting DNS stated CNA #2 was afraid of CNA #1 and did not want to report him for fear of retaliation by CNA #1. The Acting DNS stated an I&A was completed on 12/21/18, however, he back dated the I&A to 12/20/18, to reflect the date the abuse occurred. The I&A Report, dated 12/20/18, documented, it was discovered that a Staff member had caused multiple skin tears to various residents (this Resident included) from being rough during cares. CNA #2 witnessed CNA #1 yelling, [***] you! [***] you! [***] you! in Resident #27's face because he had a bowel movement at the change of shift. The report also documented Resident #27 sustained a skin tear on the front of his left forearm. The report documented Resident #27 was unable to recall the incident. There was no documented evidence the facility completed a thorough investigation of the physical and verbal abuse which occurred on 12/20/18. The physical abuse investigation lacked documentation of the size or extent of the skin tear to Resident #27's left forearm, staff or resident interviews to determine the origin of the skin tear, or progress notes identifying the progression of the skin tear. The verbal abuse investigation did not document potential verbal abuse was ruled out for other residents. The investigation did not include witness statements regarding the physical or verbal abuse. The IDT follow-up note for the 12/20/18 verbal abuse and skin tear to the left forearm, dated 12/26/18, documented Resident #27 sustained two skin tears on 12/16/18 and it was discovered that the cause of the skin tears were from CNA #1 handling Resident #27 roughly. The follow up note documented CNA #1 was also accused of swearing profanities in Resident #27's face and transferred him incorrectly and sustained two skin tears on 12/16/18. The report documented Resident #27 was transferred by CNA #1 lifting him up and placing him in his wheelchair. Resident #27 was not lifted in the mechanical lift like he should have been. The IDT 12/26/18 follow-up note did not document how and when it was determined Resident #27 was incorrectly transferred by CNA #1. The report documented CNA #1's employment was terminated for verbal and physical abuse. On 1/7/19 at 2:00 PM, the Acting DNS and the Administrator Designee stated CNA #2 was not comfortable reporting the witnessed abuse to the charge nurse at the time of the incident while CNA #1 was in the building. The Acting DNS stated the facility educated CNA #2 on reporting allegations of abuse immediately, however, they did not document the education provided to CNA #2. The Administrator Designee stated the facility's I&A reports were incomplete. The Acting DNS stated the facility should have documented witness statements from all staff and residents. The Administrator Designee stated the investigation should include documentation of the education provided to CNA #2 about reporting allegations of abuse immediately. The Administrator Designee stated this process was not completed for the 12/16/18 and 12/20/18 I&A reports. The Administrator Designee stated the facility investigated injuries of unknown source as potential abuse. 2. Resident #225 was admitted to the facility on [DATE], with multiple diagnoses, including dementia. Resident #225 experienced an incident which was not thoroughly investigated as follows: An I&A Report, dated 12/1/18, documented Resident #225 sustained a 2.0 cm by 2.0 cm skin tear to the back of her right calf. The report documented there were no witnesses found. There was no documented evidence the facility completed a thorough investigation of the injury of unknown source which occurred on 12/1/18. The injury of unknown source investigation did not include an assessment of Resident #225's right calf, staff or resident interviews to determine the origin of the skin tears, progress notes identifying the progression of the skin tears, and/or witness statements. Resident #225's record did not document implementation of preventative measure to protect her from further injury. The IDT follow-up note for the 12/1/18 skin tears, dated 12/4/18, documented Resident #225 was transferred with a mechanical lift and the sling was removed forcefully causing a skin tear to the back of her right calf. On 1/10/19 at 11:29 AM, RCM #2 stated Resident #225's skin tear was thought to be caused by CNA #1 when he provided cares roughly. On 1/10/19 at 11:45 AM, the Administrator Designee and the Acting DNS stated CNA #1 was rough during cares with multiple residents and it was determined he physically abused residents. The Administrator Designee stated the facility had not thought to investigate verbal abuse for other residents who received cares from CNA #1 during his employment at the facility.

Based on observation, staff interview, record review, review of I&A reports, and policy review, it was determined the facility failed to ensure residents did not develop avoidable pressure ulcers. This was true for 1 of 6 residents (Resident #40) reviewed for pressure ulcers. Resident #40 was harmed when an avoidable facility acquired right heel pressure ulcer was identified and worsened. Findings include: The facility's Pressure Ulcer Prevention/Treatment policy, effective (MONTH) (YEAR), documented the need to manage friction and shear and to select appropriate interventions to stabilize, reduce, or remove underlying risk factors. For residents at high risk to develop a pressure ulcer, interventions included supplementing turning with small shifts in body position and to reduce pressure to the heels. The procedure included managing pressure by off-loading heel pressure and to manage friction and shear with heel protection if they were being exposed to friction. Resident #40 was admitted to the facility on [DATE], with a septic (infected) left knee following knee surgery, severe malnutrition, toxic metabolic [MEDICAL CONDITION] (impaired brain function related to infection, toxins, or organ failure), and uncontrolled pain. A History and Physical (H&P), dated 8/31/18, documented Resident #40 was admitted to the facility from a local hospital following a fall at home. Resident #40 fell and was not found down at his home for 2 days. The H&P documented he had multiple necrotic (dead tissue or skin) [MEDICAL CONDITION] but did not describe where the [MEDICAL CONDITION] were located. The H&P documented he was being followed by a wound clinic for the [MEDICAL CONDITION]. An admission MDS assessment, dated 9/5/18, documented Resident #40's cognition was severely impaired but he was able to express ideas and wants, make himself understood, and understood others; he did not reject evaluations or cares; he required 2-person total assistance for bed mobility, dressing, toilet use, and personal hygiene; pain was almost constantly at 6 on a scale from 0-10 (0 = no pain, 10 = worst pain); he had surgical wounds and skin tears and he was at risk for developing a pressure ulcer. A pressure ulcer Care Area Assessment (CAA) triggered by the MDS assessment, dated 9/5/18, identified Resident #40 was at an increased risk for pressure ulcers related to his surgical wounds to the left knee and left shoulder and multiple trauma wounds to the left eye/temple area, left hand/elbow/arm, left chest/shoulder, left lateral knee, left hip, and the right medial metatarsal (end of the foot by the toes). Resident #40's Braden Scale assessment (a tool for predicting pressure ulcer risk), dated 8/29/18, documented he was at high risk for developing a pressure ulcer. Resident #40's care plan included the following concerns and associated interventions: * ADL self care performance deficit: - Required a mechanical lift and the assistance of 2 staff for transfers, revised on 9/3/18. - Totally dependent on the assistance of 2 staff for repositioning and turning in bed, initiated on 9/3/18. * Safety device: air mattress with internal bolsters: - Apply safety device while in bed, initiated on 9/3/18. * Actual pressure ulcer and potential for pressure ulcer: - Needs pressure relieving mattress and pillows under calves (as he allows) to protect the skin while in bed, initiated and revised on 9/3/18. - Notify nurse immediately of any new areas of skin breakdown: redness, blisters, bruises, discoloration noted during bath or daily care, initiated on 9/3/18. - Assist with turning and repositioning at least every 2 hours, and as needed or requested, initiated on 9/3/18. - If treatment was refused, confer with Resident #40, the Interdisciplinary Team, and family to determine why and try alternative methods to gain compliance. Document alternative methods. These interventions were initiated on 9/3/18. - Keep heels off of bed by placing calves on pillow as resident allows, Sage (protective padded boots) boots to b/l (bilateral) feet, initiated on 9/3/18 and revised on 9/7/18. A Nursing Progress Note, dated 8/29/18 at 2:41 PM, documented Resident #40 refused a skin assessment. A Nursing Progress Note, dated 8/29/18 at 7:41 PM, documented staff was unable to complete a skin assessment due to Resident #40 refusing. A Therapy Progress Note, dated 8/31/18 at 7:29 AM, documented Resident #40 was at high risk for skin breakdown due to him refusing position changes or mobility with therapy. A Nursing Progress Note, dated 9/2/18 at 9:49 PM, documented Resident #40 continued to refuse re-positioning. There was no documentation regarding his wounds or skin. A Nursing Progress Note, dated 9/3/18 at 11:19 AM, documented Resident #40 Arrived with 7 previously documented wounds including pressure areas as well as trauma injuries. There was no documentation where the 7 wounds were located or a description of the wounds. The note documented an air mattress with bolsters was in place and skin and positioning programs were also in place. The note documented these were effective because there were no new skin issues since admission. A Nursing Progress Note, dated 9/5/18 at 10:14 AM, documented Resident #40 was bed bound and required the assistance of 2 staff for bed mobility and cares. The note documented the dressings to his wounds were intact and changed the previous day. There was no documentation of a description of the wounds which were dressed or where they were located. A Nursing Progress Note, dated 9/6/18 at 6:51 PM, documented Resident #40 stated his pain was uncontrolled and he wanted to go to the hospital. The note documented the on-call physician was contacted and an order was received to send Resident #40 to the hospital for evaluation and treatment. A Nursing Progress Note by RCM #1, dated 9/7/18 at 2:30 PM, documented Resident #40 had a fluid filled blister on his right heel which measured 8cm by 7cm. Staff from the hospital's Emergency Department (ED) identified the wound. RCM #1 documented the wound was cleansed with normal saline, covered with a dressing, and wrapped in gauze. RCM #1 documented the physician was notified and treatment orders were requested. She also documented Sage boots were applied to both feet and were added to Resident #40's care plan. An I&A report, dated 9/7/18 at 2:10 PM, documented Resident #40 returned from the ED and the ED staff called the facility to report a blister to his right heel. The report documented ED staff informed the facility they had drained the fluid from the blister. RCM #1 documented his right heel was assessed by herself and another nurse and they found a large blister measuring 8 cm by 7 cm. Immediate action taken included cleansing and dressing the heel pressure ulcer and they applied Sage boots to both feet. Resident #40's (MONTH) (YEAR) TAR documented weekly skin assessments were to be done every Wednesday and to document (-) for no area of impairment or (+) for area of impairment. The area to document the weekly skin check on Wednesday 9/5/18 contained a set of initials and the space to document (-) or (+) was blank. The remaining weekly skin assessments for (MONTH) (YEAR) were left blank. Resident #40's wound assessment flowsheet documented his right heel pressure ulcer was initially identified on 9/7/18, as a Stage II and it was 8 cm by 7 cm, with scant drainage and it was not present on admission. A Stage II pressure ulcer is defined as partial thickness skin loss and may present as an abrasion, blister, or shallow crater according to the National Pressure Ulcer Advisory Panel, website accessed on 11/28/18. Subsequent wound assessment documentation included the following: * 9/14/18 - Stage II pressure ulcer, unchanged in size, and heavy serosanguineous (a yellowish fluid with small amounts of blood) drainage. Comments included No change, unstageable D/T (due to) fluid filled blister. * 9/21/18 - The pressure ulcer stage was blank, the width increased to 8 cm, and the ulcer had a scant amount of serosanguineous drainage. Comments included .Unruptured blister. (No) pain noted with wound care. Updated resident on wound status. * 9/28/18 - The pressure ulcer stage was left blank, the size decreased to 7.2 cm by 6.6 cm. No drainage was documented, and the color was described as pink and black. Comments included 25% [MEDICATION NAME] (new tissue), 75% eschar (dead tissue). Wound improving . * 10/5/18 - The pressure ulcer was documented as unstageable and the size decreased to 7.0 cm by 6.6 cm. No drainage was documented, and the color was described as pink and black but, in the comments, it documented the ulcer was 100% eschar. * 10/12/18 - The pressure ulcer was documented as unstageable and the size increased to 7.5 cm by 7.0 cm. Comments included .95% eschar, 5% granulation with a small amount of purulent (containing pus) discharge. * 10/19/18 - The pressure ulcer stage was blank, the size decreased to 7.0 cm by 5.0 cm wide, with a light amount of serosanguineous drainage, and the color was described as red and black. Comments included Improving (with) 10% granulation, 90% slough (dead tissue which is yellow in color) . * 10/26/18 - The pressure ulcer stage was blank, the size increased to 7.4 cm by 5.4 cm wide, with light serosanguineous drainage, and the color was described as red and black. Comments included, Improving - measured by different provider so measurements different .Refer to chart for (name of wound care provider) notes. * 11/2/18 - The pressure ulcer stage was blank, the size decreased to 3.8 cm by 3.8 cm, with light serosanguineous drainage, and the color was described as red and black. Comments included Improving .75% eschar, 25% granulation . The wound care provider's notes, dated 10/26/18, documented this was the initial encounter for the right heel pressure ulcer and described the ulcer as Obscured full-thickness skin and tissue loss with light serosanguineous drainage. The pressure ulcer wound was further described as necrotic tissue with 51-75% eschar and 1-25% pink granulation tissue, and it measured 7.4 cm by 5.4 cm. The provider note dated 11/2/18, documented the pressure ulcer was unchanged in appearance and had decreased in size to 3.8 cm by 3.8 cm. Resident #40 was observed lying in bed with the Sage boots on both feet on 11/5/18 at 10:15 AM, 11:10 AM, and 11:25 AM, and again on 11/6/18 at 11:18 AM and 3:49 PM. On 11/7/18 at 12:45 PM, RCM #1 said Resident #40 went to an ED on 9/6/18, for uncontrolled pain and the right heel pressure ulcer was found while he was in the ED. RCM #1 said whole body skin checks were to be done weekly and documented in the TAR. RCM #1 reviewed Resident #40's record then said she would go to medical records to find his TARs for (MONTH) and (MONTH) (YEAR). On 11/7/18 at 3:04 PM, RCM #1 said she was very familiar with Resident #40 and he frequently refused to be repositioned because of pain. RCM #1 reviewed his record and found progress notes which documented he refused to get out of bed or to be repositioned on 9/6/18 at 10:51 AM and he was uncooperative with cares on 9/5/18 at 2:05 AM. She said she did not find documentation staff had provided him education about the risks associated with the refusals. RCM #1 said an air mattress was implemented on 9/3/18, 6 days after he was admitted to the facility, and Sage boots were added after he returned to the facility on [DATE]. She said Resident #40 went to the ED on 9/6/18 at 10:30 PM and he returned to the facility at 1:20 AM on 9/7/18, less than 3 hours later. RCM #1 also reviewed his (MONTH) (YEAR) and (MONTH) (YEAR) MARs and TARs and said the weekly skin check on 9/5/18 was incomplete. She said it did not document if there was or was not a new skin issue. RCM #1 said the remaining weekly skin checks for (MONTH) (YEAR) were not done and weekly skin checks were not consistently done in (MONTH) (YEAR). On 11/8/18 at 1:40 PM, LPN #7 was observed as she performed wound care and a dressing change to Resident #40's right heel pressure ulcer. When LPN #7 removed the old dressing, 3 distinct wound areas were observed at the medial (inside) and posterior (back) aspect of the right heel. LPN #7 did not measure the wounds. The largest wound was about 2.5 cm by 3 cm long and 3.5 cm by 4 cm wide and covered with 100% eschar. The two smaller open wounds had beefy red wound beds. One of the small wounds was about 1 cm long by 1.5 cm wide and the other small wound was about 0.5 cm long by 0.5 cm wide. There was approximately 0.5 cm to 1 cm of intact skin between all of the wounds. When asked about the 3 distinct wounds, LPN #7 said the smaller open areas had become evident as the overall size of the pressure ulcer decreased in size. On 11/14/18 at 12:47 PM, the Bureau of Facility Standards received a 2 page fax (including a cover sheet) from the facility. The fax was a letter by the wound care provider from the wound clinic, dated 11/12/18. The Physician Assistant Certified (PA-C) stated Based on the review of documentation before our initial visit on (MONTH) 5th, it appears his pressure injury was more than a clear fluid-filled blister (stage two) and indeed included blood. In this case this (Resident #40's name) right heel presented as a more severe Deep Tissue Pressure Injury (DTPI), which represents a much deeper area of ischemia and tissue damage. DTPI's also have a high likelihood of evolving into an open wound, which in this case it has. The facility was aware Resident #40, who was admitted with uncontrolled pain and multiple areas of skin breakdown, including [MEDICAL CONDITION], was at high risk of developing a pressure ulcer. He was harmed when the facility failed to implement interventions to minimize, reduce, or prevent pressure to his right heel, or to monitor his skin for potential breakdown and he developed a Stage II pressure ulcer to his right heel that had to be drained and was determined to be an unstageable DTPI according to the wound clinic.

Based on observation, resident and staff interview, and record review, it was determined the facility failed to ensure residents did not develop avoidable pressure ulcers in the facility, nor did the facility ensure interventions to prevent pressure ulcers were implemented. This was true for 3 of 5 residents (#s 1, 4, and 7) sampled for pressure ulcers. Resident #4 was harmed when she developed an unstageable pressure ulcer to her left heel, and did not have all prescribed measures in place to promote healing once the pressure ulcer developed. Residents #s 1 and 4 had the potential for more than minimal harm when they were not provided with offloading boots per their respective plans of care to prevent pressure ulcers. Findings included: 1. The facility's Procedure for Pressure Ulcer Prevention/Development, Effective November 1998, Revised January 2008 and April 2009, documented, "...requires the use of the Braden Risk Assessment...All residents will be assessed on admission and weekly for four weeks...The following interventions are efforts to stabalize, reduce, or remove underlying risk factors." For the "At Risk" residents, identified as a Braden score of 15-18, the procedure documented, "...reduce pressure to heels...manage...friction and shear..." Resident #4 was originally admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. The facility discharged the resident to the acute care hospital and readmitted her to the facility on 2 occasions, with the most recent readmission to the facility documented as 2/13/14. On 1/6/14, a Braden Risk Assessment Scale for the resident documented her pressure ulcer risk at a score of 18, which indicated minimal risk. Resident #1's admission MDS assessment, dated 1/13/14, coded: *BIMS of 15, indicating the resident was cognitively intact; *Not resistive to cares, no other behavioral symptoms; and *Extensive assist of 2 for bed mobility and transfers. The resident's care plan, initially dated 1/6/14, documented an "Assessment/Problem" area of, "At risk" of skin breakdown. The form for the care plan contained columns with pre-printed options for "Assessment/Problem", "Goal", and "Interventions", along with a check box next to these options to indicate which specific items applied to the resident. There were also blank columns, labeled as "Date" for the "Assessment/Problem" column, and, "Due date" for the "Interventions" column. Several dates were listed in the date and due date columns, so it was unclear when, exactly, the problems and interventions had been identified or updated. However, a hand-written addition, dated 3/5/14, was made under the "Assessment" area of the care plan which documented, "(Left) heel neuropathic ulcer (full thickness with pressure.)" Under the "Interventions" column, the option of, "Position calves on pillows to elevate heels off of the bed", was unchecked. There were no care plan assessment areas which indicated the resident was non-compliant, nor any approaches to address non-compliance. (NOTE: No MDS significant change assessment had been completed by the facility since the onset of her pressure ulcer as documented on 3/5/14 and the facility's annual recertufucation survey of 3/24/14.) Facility documentation regarding the wound included a "Skin Grid - Pressure/[MEDICAL CONDITION] Ulcer/Other" form (PU form), Physician's Telephone orders (PTOs), facility physician's notification forms, Braden skin assessments, "Admission Skin Assessment" forms, Resident Incident forms (I/As), "Pressure Ulcer Healing Chart" (PUSH) forms, Physician's Progress Notes (MD PNs), Nurse's Progress Notes (PNs), physician's orders [REDACTED]. (NOTE: The PUSH form in Resident #4's record was identified as PUSH Tool version 3.0 from the National Pressure Ulcer Advisory Panel. The directions on the form documented, "Observe and measure pressure ulcers at regular intervals using the PUSH tool. Date and record PUSH Sub-scores and Total Scores on the Pressure Ulcer Healing Record Below.") *On 1/23/14, an MD PN documented, "...seen for evaluation of ongoing leg and body pain. She was sent to the ER last weekend due to sudden onset of severe (left) hip pain...Portable X-ray showed a dislodgement of her prosthesis..." *On 1/27/14, an MD PN documented, "Since ER visit for (left) hip dislocation, she has had on-going (left) hip pain again. No known trauma..." *On 2/13/14, the date the resident was most recently admitted to the facility, the Admission Skin Assessment sheet documented no skin concerns with either of her feet. *On 3/2/14 at 8:19 AM, a facility I/A documented, "resident complained of a sore left heel on assessment noted pressure area to heel...stated it hurt for a couple of days and was told to float heels...didn't float heels because she didn't know what that meant." *The 3/2/14 I/A Post Incident Action documentation included, "floated heels and requested an order for [REDACTED]. *The 3/2/14 I/A Investigation Summaries documented, "Wound specialist saw resident on 3/4 assessed (left) heel site. Dx of (left) heel neuro pathic (sic) ulcer (full thickness with pressure). Probable cause related to this res has had recent (left) hip surgerys (sic)." *On 3/2/14, a facility physician notification form documented, "Resident has pressure area 1.0 cm X 1.0 cm on left heel..." (NOTE: The form documented no further description of the wound for physician notification.) *On 3/2/14 a PU form documented a Stage II pressure ulcer to the left heel, 1.0 cm in length X 1.0 cm in width, with no documented depth. The form was modified on 3/4/14 to document, "(Left) heel neuropathic ulcer (full thickness with pressure)." *On 3/3/14 at 7:07 PM, an MD PN documented, "...Per staff, (Resident #4) had developed an area of softening and skin breakdown on (left) heel..." (NOTE: This development was not addressed in the physician's plan of treatment documented on the MD PN. Additionally, the area was described on the 3/2/14 PU form as "full thickness with pressure.") *3/4/14 the PU form documented the wound as, "U" for unstageable, 3 cm X 4.2 cm X 0.2 cm. "Per (Wound Nurse's name) - unstageable D/T small questionable area... most of wound bed St(age) II...Sage boots at all times." *A 3/4/14 PTO documented a [DIAGNOSES REDACTED]." Orders were documented as, "...Sage boots on at all times..." *A 3/5/14 Braden Risk Assessment Scale documented the resident's risk for pressure ulcers was documented as an 18, which indicated minimal risk of pressure ulcer development. (NOTE: This was the first pressure ulcer risk assessment noted since Resident #4's most recent re-admission to the facility on [DATE], and was the same score as the resident had received prior to her skin breakdown. The score had not changed although the resident had dislocated her hip and was required to wear a brace for stabalization, and had developed a pressure ulcer on her left heel. The facility assessed the resident had not changed in her activity level, mobility, or friction and shear risk despite the above identified changes.) *On 3/6/14, Resident #4's PUSH tool documented the area of the wound (length times width, in centimeters) as "9", exudate amount as, "0", and tissue type as, "1" (epitheal tissue), with a total PUSH score of, "10." *A 3/11/14. the PU form documented the wound as, "Neuropathic ulcer," 3 cm X 4.5 cm X 0.2 cm. *On 3/12/14, Resident #4's PUSH form documented an area of, "9", exudate amount as, "1" (light), tissue type as "1", and a total PUSH score of, "11", indicating deterioration from the 3/6/14 score. *On 3/18/14, an MD PN documented, "The patient states that she is using Sage boots bilaterally when in bed, but the Velcro is bad and they come loose,,,Ulcer of the...left heel, healing slowly...Continue pressure-reducing boots to bilateral (lower extremities) at all times except when standing or ambulation...avoid use of left shoe until heel ulcer is resolved..." *A 3/18/14 PTO documented, "Please obtain new offloading boot (old one falls off) for left lower extremity...document refusals..." (NOTE: There was an area on the resident's TAR for March 2014 to document resident refusals. The area was blank, which indicated the resident had not refused use of the boot.) *A 3/18/14 PU form documented the wound as, "Neuropathic ulcer," 1.8 cm X 2.2 cm X 0.2 cm. "...Cont(inue) to educate res(ident) on pressure relief..." *On 3/18/14, Resident #4's PUSH form documented area as, "6", exudate amount as, "1", tissue type as, "2" (granulation tissue), and a total PUSH score of, "9", indicating overall improvement in the pressure ulcer since the 3/12/14 assessment. *A 3/25/14 PU form documented the wound as "Neuropathic Ulcer, " 1.8 X 3 X 0.2 cm. "...Res(ident) educated on importance of pressure relief (and) use of Sage boot to (left) foot." *On 3/25/14, Resident #4's PUSH form documented an area of, "6", exudate amount of, "0", tissue type of, "2", and an overall PUSH score of, "8", indicating overall improvement since the 3/18/14 assessment. *On 3/25/14 at 1:30 PM, R #4's physician documented, "Given the patient's co-morbid conditions at the time of the L heel ulcer formation...the heel ulcer would be considered un-avoidable." On 3/25/14 at 9:00 AM, the resident was observed sitting in her wheelchair in her room. Her left heel was resting on the foot pedal. She was wearing only a yellow slipper sock on her left foot. A blue padded boot was lying on the floor underneath her wheelchair. The resident stated she had a sore on her left foot. The resident stated, "I got that from it rubbing on the bed." The resident stated that since the development of the sore, "Now sometimes they lift my heels off the bed with pillows." At 9:10 AM, CNA #8 entered the resident's room and stated, "(R #4), your boot has come off. Can I put it back on for you?" The resident was agreeable to having the blue padded boot placed on her left foot. On 3/25/14 at 12:00 noon, CNA Student #9 was observed pushing the resident in her wheelchair to the dining room for lunch. The resident was wearing only yellow slipper socks on her feet, with the backs of her feet and heels resting on the foot pedals. The blue padded boot was not present. The resident was observed in this state throughout the lunch meal, until 12:50 PM. At 12:50 PM, CNA #1 was observed to take the resident to her room. In less than 5 minutes, CNA #1 returned to the lobby area with the resident. She was now wearing Deerfoam-type slippers on her feet, with the backs of her feet and heels continuing to rest on her foot pedals. The CNA escorted the resident outside to the facility van, where she left the facility to go to a physician's appointment. The surveyor returned to the resident's room, and noted the blue padded boot to be lying on the resident's bed. At 2:00 PM, the resident was still out of the facility at her physician's appointment. On 3/25/14 at 2:45 PM, the surveyor observed the resident to be back in the facility, sitting in her wheelchair in her room. She was still wearing the Deerfoam-type slippers on her feet, which were resting on her foot pedals, and the blue padded boot was still on her bed. The resident stated the footwear she had on was what she had been wearing since she left for her physician's appointment. The surveyor left the room and summoned the DNS. The DNS arrived at the resident's room. The DNS identified the blue padded boot on the resident's bed as a, "Sage boot," which the resident was to wear due to the pressure ulcer on her foot. The DNS was asked if the footwear the resident currently had on was considered pressure-relieving, the DNS stated, "No." On 3/25/14 at 2:50 PM, the DNS brought CNA #1 to talk with the surveyor. CNA #1 stated he took the resident back to her room after lunch to get her sweater, and the resident insisted on having her Sage boot removed and her Deerfoam-type slippers put on. When informed of the surveyor's observations of the Sage boot not being on at lunch, the CNA stated, "Oh. She didn't have it on at lunch. She was wearing her yellow slipper socks. But she insisted she wanted to wear those other slippers to her appointment." CNA #1 was asked if the resident had been educated about the benefit of wearing the Sage boot. The CNA stated, "All the time." CNA #1 was asked if the nurse had been informed of the resident's refusal to wear the Sage boot on the outing, the CNA stated, "No. I didn't tell the nurse." The DNS stated, "Well, (R #4) is non-compliant. You can ask the RCM about it. She's always non-compliant with this kind of thing." The DNS was asked if the resident had been educated about the potential consequences of her non-compliance, and if the facility had tried to overcome her objections to utilizing the Sage boots. The DNS stated, "Oh, yes." The DNS was asked if this information would be included in the resident's record and included in her care plan. The DNS stated, "It should be." On 3/26/14 at 1:05 PM, RCM #3 was asked about the pressure ulcer on the resident's left heel. The RCM stated: *The resident developed the pressure ulcer because she had been "so compromised" by her [MEDICAL CONDITION] and subsequent dislocation. *The RCM was unable to identify specific interventions put in place to protect the resident's heels from skin breakdown in light of the resident's compromised status. After reviewing the resident's care plan, the RCM was unable to determine when problems or interventions had been identified or implemented regarding the resident's risk for skin breakdown, aside from the entries noted on 3/5/14. *When asked why the intervention of offloading the resident's heels had not been selected for the resident's care plan, the RCM stated, "It must have been an oversight. I can't imagine we didn't do it." *When asked about the 3/2/14 I/A for the pressure ulcer (see above), and if the staff had offered to assist the resident to float her heels or just instructed the resident to, the RCM stated, "Well, she does move a lot." When asked how the resident would place pillows to float her heels, or don her Sage boot, while maintaining the strict hip precautions, as ordered by the physician, and using the 2-person assist required for bed mobility, as specified in the MDS, the RCM stated, " Well, she did progress to one-person assist at one time." (NOTE: On 3/27/14 at 9:00 AM, RCM provided 2 memos. The first documented the resident had been upgraded to one-person assist for transfers per therapy on 3/18/14. The second documented the resident was downgraded to a 2 person assist again after a fall on 3/23/14. The facility I/A documented the development of the pressure ulcer on 3/2/14.) *The RCM suggested perhaps the pressure ulcer developed during one of the resident's hospitalization s. However, the resident's most recent admitted was 2/13/14, and the pressure ulcer was first noted 3/2/14, 17 days later. There were no skin issues identified on Resident #4's Admission Skin Assessment form, completed 2/13/14.) *When asked whether the resident was non-compliant or resistive to cares, the RCM stated, "No, not at all. She is one of the nicest people you could meet. She does get restless and move around a lot, so I think the boots come off, but she will let you put them back on." On 3/26/14 at 3:15 PM, 2 surveyors observed RCM #3 and the DNS-In-Training (DNSIT) change the dressing on R #4's left heel. The DNSIT positioned and held the resident's leg while RCM #3 changed the dressing. The wound was on the lateral aspect of the resident's left heel. RCM #3 measured the wound as 2.4 cm X 1.8 cm. RCM #3 did not measure the depth of the wound. There was a crescent moon-shaped darkened area along the distal aspect of the wound. This area of the wound was not measured as part of the wound assessment. It appeared to cover approximately 1/3 of the circumferance of the wound. The DNSIT stated, "At one point it was unstageable because we couldn't see the wound bed. Now we can see the wound bed, so it's visualized as a Stage II. But we can't reverse stage, so it's considered unstageable." RCM # 3 described the wound as, "Pink and getting more superficial." When asked to describe the darkened crescent moon-shaped area, RCM #3 stated, "Around the edges, it's unstageable, because we can't see the wound bed." (NOTE: Neither RCM #3 nor the DNSIT was able to explain how the wound could be considered both "Unstageable" and "Stage II" at the same time. RCM #3 stated the wound bed could not be visualized under the darkened area, and no depth measurement could be obtained.) On 3/27/14 at 10:15 AM, the surveyor was present as the resident's physician (MD) changed the dressing and assessed the resident's heel. The wound was not measured, but appeared consistent with the surveyor's observations the day before. On 3/27/14 at 10:30 AM, the MD and the facility Administrator were then interviewed about the resident's pressure ulcer. The MD stated the wound looked "good", and was "healing nicely." The MD was asked about the development of the pressure ulcer (NOTE: The MD did not object to, nor correct, the term "pressure ulcer" during the conversation.) The MD stated the resident was a complicated case because of her medical history. The MD was informed about the lack of heel protection on the resident's care plan, the details of the incident report regarding the pressure ulcer, and the surveyor's observation of the blue padded boot not being in place. The MD stated, "Hmm. I remember on two occasions seeing her heels floated. I think that was right after a trip to the ER, but it's hard to say if it wasn't documented." The Administrator stated, "But today it's obvious it was always a Stage II. It was never a Stage IV." The Administrator was informed of the dressing change observation on 3/26/14, and the assessment of the DNSIT and RCM #3 that the wound was unstageable. The Administrator stated, "But it's so shallow, it's obviously not a Stage IV." The MD and the Administrator stated they were unable to visualize the entire wound bed during the 3/27/14 dressing change, due to the darkened crescent moon-shaped area. The MD and Administrator were also informed of the wound nurse's documentation of the area being unstageable, full thickness loss with pressure. The MD stated, "I don't think we were aware that calling it that meant harm. I think the wound nurse was trying to help us by calling it unstageable." On 3/27/14 at 3:15 PM, the Administrator and DNS were informed of the surveyor's findings. On 3/31/14, the facility mailed additional information regarding the deficiency at F 314, including a 3/27/14 dictation from the physician which documented, "...(Left) heel ulcer examined and is consistent with neuropathic ulcer that would be considered unavoidable given medical co-morbities at time of the event. Initial exam was deemed un-stageable since base of ulcer site could not be seen..." However, the physician's dictation did not address the surveyor's concerns that: *The facility did not implement interventions, per regulatory requirement and facility policy and procedure, to prevent pressure ulcers to Resident #4's heels, even though she had a number of known risk factors, including decreased mobility to her left lower extremity following a [MEDICAL CONDITION] and subsequent dislocation of the surgical repair; *The facility I/A at the time the wound was first noted identified the nature of the wound as, "pressure", and the cause as the resident not floating her heels because she did not know what that meant; *The wound nurse's assessment of the wound after its development which documented the nature of the wound as neuropathic with pressure, and the wound as unstageable; *The facility was using PUSH forms, identified as specific to tracking pressure ulcers, and had identified pressure as a component on other skin assessment forms used to track the progression of the wound; *The physician had not documented on the nature of the wound between the time of its discovery on 3/2/14 and the surveyor's inquiry on 3/27/14; *The resident was assessed as cognitively intact, and stated the wound resulted from her heels rubbing on the bed; and *The surveyor had observations of pressure prevention measures, specified in Resident #4's care plan, to not be implemented. 2. Resident # 7 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #7's most recent quarterly MDS assessment, dated 2/18/14, coded in part: * BIMS score of 14 indicating intact cognition; * Extensive assistance needed with 1 person for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, personal hygiene and bathing; * At risk of developing pressure ulcers; and, * No healed or unhealed pressure ulcers. Resident #7's Care Delivery Guide documented, "(Right) Heel wear sage boot." No date was provided for the intervention. Resident #7's March 2014 recapitulated physician's orders [REDACTED]." The date provided was 1/13/12. The March 2014 Treatment Administration Record for Resident #7 documented the aforementioned physician's orders [REDACTED]. The following observations were made of Resident #7 without the sage boot on her right heel: * 3/25/14 at 8:45 a.m., the resident was sitting in her room in the wheelchair. The resident was wearing slippers on both feet as her feet rested on the foot pedals of the wheelchair; * 3/26/14 at 6:04 p.m., the resident was sitting in her room in the wheelchair with slippers on both feet. The resident denied having worn a cushion boot to either foot and said she had not worn one since she was admitted to the facility; and, * 3/27/14 at 8:15 a.m., the resident was sitting in her room in the wheelchair with slippers on both feet. On 3/27/14 at 10:06 a.m., RCM #3 was asked why Resident #7 needed a sage boot to her right heel. The RCM stated the resident, "Bruises really easily and her skin is really fragile." The RCM was informed of the observations of the resident without the sage boot at which she responded, "She probably did at one time. I'll go talk to her about it." On 3/27/14 at 3:10 p.m., the Administrator and DON were informed of the sage boot issue. However, no further information or documentation was provided. 3. Resident #1 was originally admitted to the facility in 2012 and readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's 6/7/13 admission MDS coded cognition intact, required extensive assistance of one person for ADLs except eating, at risk for developing pressure ulcers (PUs), no current PUs, and pressure relieving devices for chair and for bed. Section V of the MDS documented the PU care area triggered and was care planned. The resident's 2/12/14 quarterly MDS coded cognition intact, required extensive assistance of one person for all ADLs except eating, at risk for developing PUs, no current PUs, and pressure relieving devices for chair and for bed. The resident's "Skin Integrity Assessment: Prevention and Treatment Plan of Care" identified the 5/31/13 problem, "Protect heels." One of the interventions was, "Sage boots on when in bed." The resident's 3/14 physician's orders [REDACTED]." The resident's 3/14 TAR documented, "10/25/13 resident to wear sage boots when in bed" during day, evening and night shifts. The 3/14 MAR indicated [REDACTED]. On 3/26/14 at 1:40 p.m., the surveyor observed a pair of Sage boots (blue and grey padded foam boots with velcro straps) on the chair in the resident's room. On 3/26/14 at 5:28 p.m., the resident was observed in his room sitting in a wheelchair (wc). The Sage boots were in the same location in the resident's room as observed at 1:40 p.m. The resident was interviewed about the use of Sage boots when in bed. The surveyor pointed to the Sage boots and asked the resident about wearing the Sage boots while in bed. The resident stated, "I do not wear them." The resident lifted both his feet from off the wc footrests, moved his feet around in the air, and stated, "I haven't had any skin breakdown yet. I do not need them. My skin is fine. I did have the boots on at one time when I was in bed. While I slept, the boots would come off and the boots were just not comfortable to wear when I wanted to sleep." On 3/26/14 at 5:40 p.m., the surveyor showed the DON the documentation on the resident's 3/14 TAR, including the day, evening, and night shifts with nursing staff initials. The DON looked at the Sage boot order on the 3/14 TAR and stated, "The nursing staff initials mean the resident wore the Sage boots when in bed." The surveyor asked the DON to speak with the resident about wearing the Sage boots while in bed. On 3/26/14 at approximately 6:00 p.m., LN #7 stated, "We spoke with the resident. (Resident #1) said he can not remember when the last time was that he wore the Sage boots when in bed. We will contact the resident's doctor to request discontinue the order. The nurses have been spoken to about this concern." On 3/28/14 at 11:30 a.m., the Administrator and the DON were informed of the concern.