Every finding on record at Jamestown Nursing And Rehab, LLC

Based on observation of medication administration, interview, record review, facility document review, policy review, and the manufacturer's instructions, the facility failed to follow manufacturer's instructions during the administration of insulin for 1 (Resident #69) of 4 residents sampled for medication administration. The findings are: A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/24/2025 revealed Resident #69 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. Resident #69 had active diagnoses which included renal insufficiency and diabetes mellitus. The resident also received daily injections of insulin A review of a Care Plan Report indicated Resident #69 had diabetes mellitus, with instructions to administer medications as ordered by the physician. A review of active Physician's Orders from 05/21/2025, revealed Resident #69 had diagnoses, which included: type 2 diabetes mellitus, with diabetic chronic kidney disease. Resident #69 had an order for a long-acting insulin to be administered subcutaneously, one time a day. During an observation on 05/21/2025 at 8:40 AM, the Assistant Director of Nursing (ADON) was observed preparing an insulin pen for Resident #69. The ADON prepared the insulin pen, without priming it with two units, then administered the prescribed insulin dose to Resident #69, without holding the dose plunger in for a count of six, after the initial administration. The ADON immediately removed their finger from the plunger but held the insulin pen to the skin for a count of five. During an interview on 05/21/2025 at 8:37 AM, the ADON confirmed the insulin pen had not been primed, prior to administration, and the plunger had not been held down for a count of six, after stating the plunger had been released immediately. During an interview on 05/21/2025 at 9:26 AM, the Director of Nursing (DON) was asked how an insulin pen should be prepared, prior to administration. The DON confirmed the insulin pen should have been primed prior to administration, with two units of insulin, and the plunger should be held down for the appropriate count, after the administration, usually five to ten seconds. The DON confirmed the expectation of the staff administering medications, according to the manufacturers recommendations, and to follow the facilities policies. During an interview on 05/21/2025 at 3:21 PM, Resident #69's Primary Care Physician (PCP), confirmed the dose ordered for the insulin pen, was expected to be administered. The PCP confirmed that if a dose was ordered, then that was the dose expected to be administered. If a dose was missed, then the resident may have needed to be assessed, and the dose adjusted. A review of a Medication, General Administration of policy revealed the physician's order must be verified prior to administering medications, and a current drug reference was available. An Inservice Education Report dated 05/22/2025, was reviewed and read in part, when injecting with an insulin pen, Step seven: turn the dose select to 2 units. Step eight: Hold the pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top. Step nine: hold the pen with the needle pointing up. Press and hold the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin, repeat steps 7 to 9 . Step Thirteen: press and hold down the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. You may hear a click. Keep the needle in the skin after the dose counter has returned to 0 and slowly count to six. When the dose counter returns to 0, you will not get a full dose until 6 seconds later . The training was signed by five nursing staff. A review of the manufacturer ' s Instructions For Use, revised 07/2022, revealed the following steps: Priming your insulin pen, Step 7: Turn the dose selector to select 2 units. Step 8: hold the pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top. Step nine: Hold the pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin, repeat steps 7 to 9. To administer the insulin pen injection, insert the needle into the skin, press and hold down the dose button until the counter reaches 0, keep the needle in the skin and count slowly to six. When the dose counter returns to 0, the patient will not get the full dose until 6 seconds later.

Based on interviews and record review, the facility failed to ensure physical and psychosocial care interventions were implemented and modified to meet a resident ' s activities of daily living needs and failed to exhaust all available remedies as evidenced by the deterioration of a resident ' s physical status resulting in death for 1 (Resident #1) of 8 sampled residents. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of J. The IJ began on [DATE] when maggots were observed to be imbedded in the body of Resident #1 by staff providing care, and pain was identified by the resident as the rationale for refusal of additional assessment and care. The Administrator and Nurse Consultants were notified of the IJ on [DATE] at 11:07 AM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on [DATE] at 9:13 AM. The IJ was removed on [DATE] at 3:32 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Findings include: A review of a facility policy titled, Resident Rights, revised on [DATE], indicated facility staff were trained on resident rights and involved in the implementation of the policy and procedure. Residents have a right to be informed of their health, medical condition and treatment, participate in or refuse treatment, be advised of alternative care and treatments and their consequences. Residents have the right to 15. Receive adequate and appropriate medical care, nursing care, protective and support services, and personal cleanliness in a safe and clean environment. , 22. Be transferred or discharged on ly for medical reasons, for your welfare or that of others . , 33. Be free from physical abuse and neglect . A review of a facility policy titled, Abuse, Neglect, Misappropriation and Exploitation Investigation and Reporting Policy, revised [DATE], indicated, The Facility will endeavor to protect residents from maltreatment, which means adult abuse, sexual abuse, neglect, misappropriation of resident property, and exploitation of residents. It recognizes resident rights to be free from physical, verbal, or mental abuse, corporal punishment, involuntary seclusion, and any chemical and physical restraints as defined by federal regulation. Section II - Staff training and competency included in-service training programs that addressed resident rights, abuse policy including definitions and terminology, recognizing signs and symptoms of abuse, how and when and to whom allegations of mistreatment, neglect, and abuse will be reported, investigations on injuries of unknown origin. Section III - Identifying, investigating, and reporting, general policy included, all alleged, witnessed, or suspected resident maltreatment, including abuse and neglect shall be immediately reported to the Administrator or immediate supervisor and investigated by Facility management. All facility personnel, including all employees and any physician, owner, and Administrator, must immediately report all incidents of alleged, witnessed, or suspected resident maltreatment, including abuse and neglect, to the Administrator, or the Administrator ' s Designee who will report events as required by State law or regulation. When determining whether to report an incident, the definitions of abuse and neglect shall be considered. Any person in the facility suspecting the facility Administrator of any form of resident maltreatment or failing to report resident maltreatment is encouraged to go to the DON, consultant, or the State Agency. The Administrator or designee will immediately conduct an investigation of all incidents of alleged, witnessed, or suspected resident maltreatment. All alleged, witnessed, or suspected incidents must be reported according to state and federal law, within time restrictions required by law. All alleged violations are to be reported immediately but no later than 2 hours after allegation is made, to the Administrator, State Agency, local law enforcement, physician, coroner, State Registry, and resident ' s responsible party or emergency contact. Section IX - Definitions included Neglect, An act or omission by a caregiver responsible for the care and supervision of an endangered person or an impaired person constituting the negligent failure to: 1. Provide necessary treatment, rehabilitation, care, food, clothing, shelter, supervision, or medical services to an endangered person or an impaired person; , and 4. Provide goods or services to a long-term care facility resident necessary to avoid physical harm, mental anguish, or mental illness. Impaired person - A long-term care facility resident is presumed to be an impaired person. A Policy and Procedure was requested for catheters. The Administrator provided policy statement, We do not have a policy on urinary catheters. On [DATE] at 12:25 PM, the Administrator stated the facility did not have a policy for wound care. The Medical Director was an independent contractor, and the facility did not have a job description for the Medical Director. Review of the job description for Administrator indicated the position was to manage and direct the day-to-day operations of the facility, and to learn and implement state and federal regulations. Responsibilities of the position included resident safety, reviews complaints and grievances, maintain written policies and procedures, assist department head with eliminating and correcting problem areas. Review of the job description for the Director of Nursing (DON) indicated the position responsibilities included assuring resident safety, day to day operation and management of the nursing department and working closely with the Administrator regarding coordination of resident services and functions of the nursing department. Review of the job description for the Assistant Director of Nursing (ADON) indicated the position responsibilities included assuring resident safety and day-to-day operations of the nursing department, meeting with team members regarding coordination of resident services. Review of the job description for the Charge Nurse indicated the position responsibilities included assuring resident safety; perform nursing services for the comfort and well-being of the residents; check residents daily to determine status, assess, record, and report changes in residents ' condition to supervisor and attending physician; complete treatment orders; complete skin audits; identify nursing problems and respond and initiate immediate action; communicate problems to DON; provide emergency care to residents; assess resident needs and provide input for care. Review of the job description for the Treatment Nurse indicated the position responsibilities included assuring resident safety; completing treatment orders; assist and complete skin audits; safety of residents; identify safety hazards and special nursing problems and initiate immediate action; communicate problems and needs in nursing department; assess and report changes in resident condition and take follow-up action as necessary; provide emergency care to residents; assess resident ' s needs and provide input. Review of the job description for Certified Nursing Assistant (CNA) indicated the position responsibilities included assuring resident safety; identify resident problems and concerns and report them immediately to charge nurse or a licensed nurse; report changes in residents ' condition. A review of the Medical Director Retainer Agreement with an effective date [DATE], indicated the duties of the Medical Director included guidance and oversite in the development and implementation of resident care policies that reflect current standards of practice; responsible for coordination of medical care in the facility; identifying, evaluating, and resolving medical and clinical concerns and issues affecting resident care, medical care or quality of life or were related to the provision of services by physicians and other licensed health care practitioners. Medical care through medical doctors, Advanced Practice Registered Nurse (APRN) ' s, and telehealth services provided by the contracted provider limited liability company. A review of the medical director statement, provided by the Administrator, dated [DATE], indicated the physician designated as the Medical Director was not the physician named as the Medical Director in the Medical Director Retainer Agreement, as the agreement was between the limited liability company providing a Medical Director and the facility and not with the individual provider. A review of the Admission Assessment Communication, dated [DATE] indicated Resident #1 was a hospital referral for possible long-term care (LTC) placement. Nursing information included Resident #1 required maximum assistance of two for rolling over in bed and moving from a laying to sitting position; required assistance with oral hygiene; maximum assistance toileting and perineal care, incontinent at times; mechanical lift for transfers and no restrictions on ambulation; cognitive status was alert and oriented; had a sacral decubitus ulcer; required a wheelchair; had a mood disorder and was receiving medication. A review of the Level I Preadmission Screen, also known as the DMS-787, with a completion date of [DATE], indicated Resident #1 had a diagnosable major mental disorder indicated as panic or other severe anxiety disorder. A review of the Report of Disability Examination, also known as the DCO-0107S, with a signed date of [DATE], indicated Resident #1 had a medical history that included severe morbid obesity, unspecified mood disorder, and chronic pain. Further review indicated Resident #1 had pain with movement classified as 10 on a scale of ,d+[DATE], 10 being the worst Medications listed included a serotonin reuptake inhibitor (antidepressant), a selective serotonin reuptake inhibitor (antidepressant), two blood pressure medications, a muscle relaxant, oral opioid (pain reliever), opioid analgesic patch, and three medications for elevated blood sugar. A check box response to the question, Has the patient followed treatment recommendations? was No. Comments indicated Multiple instances - refusal of Care. A review of the Medical Review Team (MRT) Social Report for Adults, also known as the DCO-0108S, with an application date of [DATE] indicated Resident #1 ' s illness, injury, or conditions limiting ability to work or perform household activities included chronic pain described as constant pain with treatment that included wound care and pain medication. MD #1 and APRN #11 were listed as physicians seen by Resident #1 in the past year, and Resident #1 was hospitalized from [DATE] to [DATE]. A review of the Hospital Medical Discharge Summary, with a discharge date d of [DATE], indicated Resident #1 had morbid obesity, was chronically bedbound related to deconditioning and not moving much, surgically implanted catheter, poor social living scenario, and chronic pain. A note dated [DATE] indicated resident continued to refuse physical therapy and turning and there was a high concern for continued decline with refusal to comply. A note on [DATE]-[DATE] indicated Resident #1 had not been compliant with any activity. Instructions included wound care to perineal and gluteal area. A review of the Admission Agreement, signed by Resident #1 on [DATE], indicated due diligence would be used by the facility to obtain the services of a physician when the resident ' s condition required such medical attention and would attempt to obtain the services of another physician if resident ' s personal physician was unavailable. Further, the facility would obtain, at the discretion of the physician or the facility, ancillary services, such as physician or ambulance services, deemed necessary for the health and welfare of the resident. A review of the Acknowledgment of Receipt of Advanced Directive Information-Resident, signed by Resident #1 on [DATE] indicated Resident #1 chose to have continued administration of all possible medical treatment, as ordered by the physician, to prolong life to the greatest extent possible without regard to condition, chance of recovery, or expense. A review of the Capacity Verification, dated [DATE] did not indicate a capacity (an individual ' s mental or physical ability) and was signed by the resident and an unidentified facility representative. A review of the Admission Record, indicated the facility admitted Resident #1 on [DATE] with diagnoses that included pressure ulcer of the sacral region, type 2 diabetes mellitus, malaise (an indefinite feeling of debility or lack of health often indicative of or accompanying the onset of an illness), morbid obesity, mood affective disorder, and chronic pain. A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], indicated Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Resident #1 ' s mood interview, sections C through I were not completed related to negative symptom responses to the first two questions, and a total mood severity score indicated 00. Resident #1 had impairment of bilateral lower extremities, used a wheelchair for mobility, was dependent on staff for toileting and dressing; required substantial/maximal assistance with oral hygiene and personal hygiene; required setup/cleanup assistance with eating; and refused shower/bathing self. Resident #1 was dependent on staff to roll left and right, refused to sit up, refused to transfer to a chair, refused to use wheelchair, and refused to transfer for a tub or shower. Resident #1 had an indwelling urinary catheter and was continent of bowel. Active diagnoses were identified as diabetes mellitus, morbid obesity, mood affective disorder, and chronic pain described as occurring frequently and not interfering with daily activities. Prognoses of life expectancy of less than 6 months indicated no. Skin condition indicated a stage IV (most severe stage, significant tissue loss, damage extends through all layers of skin exposing muscle, tendon/bone, high risk of infection) pressure ulcer was present on admission and Resident #1 was at risk of developing pressure ulcers. Resident #1 medications received included an antidepressant and opioid. Resident #1 had a goal to remain in the facility and not return to the community. Care areas identified included activities of daily living (ADL) functional/rehabilitation potential; urinary incontinence and indwelling catheter; falls; nutritional status; dehydration/fluid maintenance; pressure ulcer; psychotropic drug use; and pain. A review of the significant change MDS, with an ARD of [DATE], indicated changes from the admission MDS included the following: Resident #1 exhibited behavior described as worsening for rejection of care occurring daily. Resident #1 refused shower/bathe, dressing, rolling left or right in bed, and any transferring; required supervision with oral hygiene. Resident #1 was always incontinent of bowel. Pain was described as effecting sleep, interfering with therapy activities, and day to day activities almost constantly, and rated as a 10 on a scale of ,d+[DATE] with 10 being the worst pain imagined. Resident #1 did not receive scheduled pain medication. Medications included an antibiotic. Care areas identified included cognitive loss/dementia and behavioral symptoms. A review of Resident #1 ' s care plan with a resolved date of [DATE], indicated Resident #1 ' s code status as full code, indicating wanting cardiopulmonary resuscitation. Interventions included providing the opportunity for resident to discuss feelings and ask questions related to end of life decisions and review code status; and a change in code status to do not resuscitate (DNR) with interventions that included checking for resident signature on consent form; verify physician order; review code status with resident annually and as needed; acknowledge right to revoke DNR status; and a. Resident #1 was placed on contact isolation on [DATE] due to wound and wound myiasis (a parasitic infection that occurs when fly larvae [maggots] burrow into the skin of a live animal and feed on its tissue) related to refusal of wound care. Interventions included pest control with a fly light trap, treatment of myiasis as ordered by physician, and wound care as ordered by physician resident refused; and b. Resident #1 had an ADL self-care performance deficit related to chronic pain, refusing ADL care, turning, wound treatment, incontinent care and catheter care. Interventions included, resident was totally dependent on 2 staff for bathing/showering, mobility, dressing, toileting, transferring with mechanical lift, was bedfast, used bedrails for independence with turning and positioning, dependent on 1 staff for personal and oral hygiene, required skin inspection and was to be observed for redness, open areas, scratches, cuts, bruises and report changes to nurse; and c. Resident #1 exhibited behaviors that included rejection of care with interventions that included providing staff training on behaviors, notification to the physician of changes in behavior, and administering and monitoring effectiveness of medications; and d. Resident #1 was resistant to care evidenced by refusal of care, to be repositioned, refused skin assessments and treatments. Interventions included allowing Resident #1 to make decisions about treatment to provide sense of control, educate on outcome of non-compliance, encourage participation during care activities, clearly explain care activities prior to contact, negotiate ADL care times to allow resident participation, change approach if Resident #1 becomes agitated and notify charge nurse of situation; and e. Resident #1 had no impaired cognitive function/dementia based on BIMS score of 15, would remain oriented to person, place, situation and time, and would maintain current level of decision-making ability. Interventions included engaging in pleasant topic conversation prior to initiating care; and f. Resident #1 was receiving opioid pain medication therapy with interventions that included administering medication as ordered by physician and monitoring side effects of the medication; and g. Resident #1 had antidepressant medications related to affective mood disorder with interventions that included administering medications as ordered and monitoring side effects and effectiveness every shift. A black box medication warning indicated observation and monitoring for suicidality, unusual changes in behaviors, and clinical worsening; and h. Resident #1 had a mood problem related to mood affective disorder with interventions that included behavioral health consults, monitoring for irritability, mood changes, and agitation; and i. Resident #1 had chronic pain with interventions to anticipate need for pain relief, evaluate effectiveness of interventions, monitor for non-verbal pain, mood/behavior changes and review impact on functional ability and impact on cognition; and j. Resident #1 had a pressure ulcer to coccyx/sacrum and potential for development of pressure ulcers and refused treatment that included wound care, turning and repositioning, wound assessments per protocol and full skin assessments. Goals included healing of the pressure ulcer, remain free of infection, and maintain or develop clean intact skin. Interventions included administration of medication and treatments as ordered, educating resident on causes of breakdown and frequent positioning; and k. Resident #1 had an indwelling catheter. Interventions included changing catheter as ordered, resident refused catheter changes and care; monitor and report signs and symptoms of urinary tract infection, that included foul smelling urine, altered mental status, change in behavior. Resident #1 refused a follow up urology appointment. A review of Order Summary Report, with active orders as of [DATE], indicated Resident #1 had an order to admit to LTC (long term care); a pain assessment every shift with a start date of [DATE]; treatment of coccyx wound daily and as needed with a start date of [DATE]; an antidepressant daily for mood affective disorder, with a start date of [DATE]; oral opioid pain medication every 4 hours as needed for severe pain with a start date of [DATE]; an opioid pain medication every 4 hours as needed for pain; an antidepressant at bedtime for mood affective disorder, with a start date of [DATE]. A review of the Nsg [Nursing] Admit/Readmit/Quarterly Assessment, dated [DATE] indicated a skin assessment integrity comment, Stage four noted to resident ' s coccyx with wet to dry treatment in place. Sensory Perception indicated Resident #1 ' s ability to meaningfully respond to pressure related discomfort was slightly limited, was able to respond to verbal commands, cannot always communicate discomfort or the need to be turned OR has some sensory impairment limiting the ability to feel pain or discomfort in 1 or 2 extremities. Resident was bedfast and had very limited mobility and was unable to make changes independently and was at moderate risk for dehydration. Cognition did not identify current psychiatric diagnoses or behavioral problem. Neurological assessment indicated resident was alert and oriented to person, place, time, and situation and was verbally appropriate. Resident #1 indicated pain occurred frequently in the last 5 days affecting sleep and day to day activities, and current pain was severe and rated it a 10 on scale of ,d+[DATE]. No behaviors were documented. A review of the Nsg Admit Skin Audit, dated [DATE] indicated Resident #1 had bruising to right and left antecubital areas related to IV sticks, dry skin, a stage 4 wound to coccyx (Stage 4 indicates full thickness tissue loss with exposed bone, tendon, or muscle.). A review of the Nsg Functional Abilities and Goals-Admission, with an effective date of [DATE] indicated Resident #1 had bilateral lower extremity impairment, required a wheelchair for mobility and was dependent for manual wheelchair use, required substantial/maximal assistance with personal hygiene, was dependent for toileting, dressing, rolling left and right, sitting to lying, lying to sitting, transferring from chair to bed and bed to chair, refused to stand from seated position, and refused shower/bathing. On [DATE] Resident #1 was seen by APRN #11 for hospital follow up. Reviewed problems included type 2 diabetes mellitus (DM), morbid obesity, anxiety, panic disorder with agoraphobia, depressive disorder, chronic pain, pressure injury of buttock, open wound of buttock, and pain in right hip joint. History of present illness (HPI) included urinary catheter surgically implanted, denied depression. Physical examination revealed morbid obesity and limited ambulation. Psychiatric mental status was normal mood and lethargic; was oriented to time, place, and person. Musculoskeletal revealed limited range of motion (ROM) and right hip pain. Assessment plan included: DM, chronic pain continue opioid; depressive disorder continue antidepressant. Open wound of buttock was not assessed. On [DATE], Resident #1 was seen by APRN #4 for open wound assessment. Reviewed problems included unstageable pressure injury, open wound of buttock with complication, pain right hip joint. HPI included reported stage 4 pressure ulcer to coccyx, present on arrival to facility. Visit was first wound care visit. APRN #4 indicated they were unable to access Stage 4 pressure ulcer to coccyx and other unknown wounds as patient currently refuses to turn for full body skin assessment. Resident reported due to pain, would turn once per day when goes to the bathroom. Review of system (ROS) indicated unable to assess wounds. Orders given for wound care, if unable to perform tele visit at time of turning. On [DATE], Resident #1 was seen via telemedicine by APRN #22 for report of change in condition, HPI indicated expired opioid order, pressure ulcer required dressing change, and pain at wound site during wound care. ROS included mental status as active and alert. The Assessment/Plan was chronic pain with a change in opioid medication. Review of a Progress Note, dated [DATE], indicated Resident #1 refused to be cleaned and refused wound care more than one time daily, and stated would allow nurse to provide care at a later time. At 10:00 PM staff notified LPN #32 Resident #1 did not want care provided. A review of Nsg Weekly Skin Audit, dated [DATE], indicated skin was intact, no wounds with narrative note that stated, Resident refuses any and all skin audits. Review of a Progress Note, dated [DATE] at 5:26 PM indicated an odor in Resident #1 ' s room suspected coming from wound. The former Assistant Director of Nursing (F-ADON) entered Resident #1 ' s room and was aware of incontinent bowel, care was attempted and resident refused to allow staff to complete incontinent care and wound care. Feces were in wound dressing, resident was advised of risk of not allowing care, resident reported that (pronoun) did not care about wound becoming infected and would rather lay in feces than to be moved. On [DATE], Resident #1 was seen by Primary Care Physician (PCP) as new admission. The problem list included morbid obesity, heart failure, DM type 2, hypertension, malaise, mood affective disorder, and chronic pain. HPI included incontinent of bladder, continent of bowel, mood stable without behavioral problems, and was compliant with medications and care. Functional assessment indicated one person assist for ADLs and transfers. ROS included no anxiety or depression. Assessment/Plan included depressive disorder - continue antidepressant, impaired ADLs - assist and monitor, degenerative joint disease (DJD) - continue pain control with opioid, assist with ADLs and monitor, moderate to severe frailty syndrome - bedbound, assist with ADLs and monitor, sarcopenia (muscle loss) - assist with ADLs and monitor, poly-pharmacy - educate on medication interaction/adverse effects and monitor for adverse effects. Review of a Progress Note, dated [DATE] at 4:43 PM indicated Resident #1 continued to refuse incontinent care and wound care, and stated, I would rather lay here and die, than to let you move me. A review of Medication Administration Record (MAR), for [DATE] ([DATE] through [DATE]) indicated Resident #1 had pain documented 9 times above a level of 0, with medication administered. A review of Treatment Administration Record (TAR), for [DATE] indicated Resident #1 refused to allow wound care [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. No as needed (PRN) wound care was documented. A review of Nsg Weekly Skin Audit, dated [DATE], narrative note indicated Resident refuses all cares, an (sic) treatments. On [DATE] Resident #1 was seen by APRN #11 for follow-up on chronic pain. HPI indicated follow up for sacral ulcer, refusing bed and incontinence changes, wound care and repositioning related to pain. ROS revealed psychiatric mental status was active and alert and normal mood, oriented to time, place, and person. Assessment/Plan indicated chronic pain, continue oral opioid and PCP ordered opioid transdermal patch. On [DATE] Resident #1 was seen by PCP for acute visit for toenail care. ROS and Exam indicated skin had no rash, itching or skin changes and was warm dry (W/D) and intact. Assessment and plan included pressure ulcer on coccyx - resident does not want to be rolled due to pain. Continue facility wound care and Monitor for infection . DJD indicated staff reporting refusal of care due to pain; resident reports pain in hips, back and bilateral knees, educated on taking medication to stay ahead of pain, resident reported still has pain 40 minutes after taking medication; educated on importance of care compliance; opioid patch ordered for pain. Review of a Progress Note, dated [DATE] at 3:20 PM and 11:29 PM indicated Resident #1 refused incontinent and wound care. On [DATE] at 2:22 PM, Resident #1 refused 3 attempts at shower to be given. On [DATE] at 4:25 AM, indicated Resident #1 rejected care. At 3:27 PM, Resident #1 continued to reject care related to incontinence and positioning. On [DATE] at 12:41 AM, Resident #1 rejected care, to be changed, and was laying in stool. On [DATE] at 7:39 PM, Resident #1 refused shower. On [DATE] at 11:37 AM, Resident #1 continued to refuse care, showers, incontinent care and wound treatment. On [DATE] at 7:37 PM, Resident #1 continued to refuse care, laying in feces. On [DATE] at 6:39 PM Resident #1 continued to refuse incontinent care and personal care, CNA offered bed bath resident became angry and threw dinner tray stating, I hate this (explicit word) place and the people here, when CNA stated they would get assistance to provide bath. Resident #1 refused positioning, incontinent care, or other ADL assistance. On [DATE] at 6:03 PM Resident #1 allowed partial bed bath and refused to be turned off back to allow for wound assessment or care. On [DATE] at 09:15 AM, Resident #1 refused 3 attempts to give shower. On [DATE] at 3:56 PM, Resident #1 had no shower given. On [DATE] at 01:09 AM, Resident #1 continued to refuse care. On [DATE] at 3:33 PM, Resident #1 refused laxative and stated has bowel movement (BM) once a week and intentionally does not eat much so does not produce much waste. On [DATE] at 02:06 AM, Resident #1 continued to refuse care. On [DATE] at 10:23 AM, Resident #1 continued to refuse care, was currently lying in feces, refuses to allow staff to clean, and stated what is the point anyway. On [DATE] at 1:14 PM, F-ADON spoke with Resident #1 regarding continued refusal of care. Resident #1 became upset and asked to be left alone. A review of a PCP note indicated on [DATE], Resident #1 was seen for an acute visit for toenail care. HPI indicated mood stable with no behavioral problems and was compliant with care. Exam included a psychiatric evaluation that described Resident #1 as calm, cooperative, alert and oriented (AO) x 3 (indicating person, place, situation), and followed commands. The Assessment/Plan indicated the facility was unable to access the wound due to refusal because the resident did not want to be rolled. Staff reported refusal of all care. Options were provided if the resident continued to refuse care, which included comfort care and transfer to another facility. Continue facility wound care. The opioid patch dose was increased and an oral opioid medication was added. Review of a Progress Note, dated [DATE] at 11:50 AM, indicated Resident #1 continued to refuse perineal care and repositioning. On [DATE] at 12:41 PM, Resident #1 refused 3 attempts to provide shower. On [DATE] at 04:01 AM, Resident #1 continued to refuse perineal and other care. On [DATE] at 12:47 AM, Resident #1 refused care, was provided scheduled pain medication, and Resident #1 stated that is not the problem nurse should be worried about. On [DATE] at 3:27 PM, Resident #1 ' s room smelled like BM and refused to allow old brief to be removed, refused to allow skin assessment. On [DATE] at 10:48 AM, a foul odor was observed in Resident #1 ' s room and sitting area outside room. The nurse asked if pain medication was needed to allow for wound care in the afternoon. Resident #1 closed eyes, held [TRUNCATED]

F686 J Based on interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure care and services were provided to prevent new pressure ulcer development and promote healing of existing pressure ulcers including admission and ongoing wound care assessments, appropriate and alternative interventions, and resident understanding of consequences of refusal; specifically no surgical interventions under anesthesia were offered, no intravenous pain medication was offered, no anti-anxiety medication was offered, the Medical Director was not made aware of or involved in care, interventions, or resident education; the Administrator did not participate in resident communications or bedside care plan meetings, no one-on-one in person counseling was sought out, behavioral history or symptoms were not used in interventions, no attempt at a competency evaluation for mental instability was made for 1 (Resident #1) of 8 residents reviewed for wound care services to treat, heal, and prevent pressure injuries. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 05/23/2024, when Resident #1 began refusing wound and incontinence care due to pain, and the facility did not provide effective interventions to alleviate the symptoms. The Administrator and Nurse Consultants were notified of the IJ on 11/27/2024 at 9:56 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 12/09/2024 at 9:13 PM. The IJ was removed on 12/10/2024 at 5:30 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Findings include: On 11/25/2024 at 12:25 PM, the Administrator stated the facility did not have a policy for wound care. The Medical Director was an independent contractor, and the facility did not have a job description for the Medical Director. A review of the facility ' s undated policy titled Resident Rights, indicated, residents had a right to; receive information in a language the resident understands, receive adequate and appropriate medical care, nursing care, protective supportive services, and personal cleanliness in a safe and clean environment, be advised by a physician or appropriate medical staff of alternative courses of care and treatments and their consequences. A review of a facility policy titled, Infection Prevention and Control Program, dated 11/22/2017, indicated the medical director was responsible for overseeing the management of an outbreak. Review of the job description for Administrator revealed the position was to manage and direct the day-to-day operations of the facility, and to learn and implement state and federal regulations. Responsibilities of the position included resident safety, reviews complaints and grievances, maintain written policies and procedures, assist department head with eliminating and correcting problem areas. Review of the job description for the Director of Nursing (DON) revealed the position responsibilities included assuring resident safety, day to day operation and management of the nursing department and working closely with the Administrator regarding coordination of resident services and functions of the nursing department. Review of the job description for the Assistant Director of Nursing (ADON) revealed the position responsibilities included assuring resident safety and day-to-day operations of the nursing department, meeting with team members regarding coordination of resident services. Review of the job description for the Charge Nurse revealed the position responsibilities included assuring resident safety; perform nursing services for the comfort and well-being of the residents; check residents daily to determine status, assess, record, and report changes in residents ' condition to supervisor and attending physician; complete treatment orders; complete skin audits; identify nursing problems and respond and initiate immediate action; communicate problems to DON; provide emergency care to residents; assess resident needs and provide input for care. Review of the job description for the Treatment Nurse revealed the position responsibilities included assuring resident safety; completing treatment orders; assist and complete skin audits; safety of residents; identify safety hazards and special nursing problems and initiate immediate action; communicate problems and needs in nursing department; assess and report changes in resident condition and take follow-up action as necessary; provide emergency care to residents; assess resident ' s needs and provide input. Review of the job description for Certified Nursing Assistant (CNA) revealed the position responsibilities included assuring resident safety; identify resident problems and concerns and report them immediately to charge nurse or a licensed nurse; report changes in residents ' condition. A review of a document titled Medical Director Retainer Agreement with an effective date 01/01/2018 stated, the Medical Director ' s services included working with the facility in identifying, evaluating, and resolving medical and clinical concerns and issues affecting resident care, medical care, or quality of life; or related to the provision of services by physicians and other licensed health care practitioners. A review of the Admission Record, indicated the facility admitted Resident #1 on 05/20/2024 with diagnoses that included chronic pain, unspecified mood disorder, morbid obesity, malaise (general sense of unwell, often with fatigue, diffuse pain, or lack of interest in activities), and congestive heart failure. On 05/31/2024 a diagnosis stated, procedure and treatment not carried out because of patient ' s decision for unspecified reasons. On 06/28/2024 a diagnosis stated, pressure ulcer of sacral region, unstageable. On 08/22/2024 a diagnosis stated, wound myiasis (a parasitic infection where fly larvae [maggots] infest and feed on living tissue in wounds). A review of the Nursing Admit Skin Audit dated 05/20/2024 at 10:11 PM, indicated a stage 4 pressure injury to the coccyx with a wet to dry dressing in place (Stage 4 pressure injuries involve full thickness tissue loss with exposed bone, tendon, or muscle.). A review of an Advanced Practice Registered Nurse (APRN) #4 note, dated 05/23/2024 at 9:55 AM, revealed Resident #1 had a medical history of anxiety, morbid obesity, panic disorder with agoraphobia (a fear of places and situations that might cause panic, helplessness, or embarrassment), depressive disorder, insomnia, chronic pain, pressure injury of the buttocks, open wound of the buttocks with complications, pain in the right hip joint. A review of the Level I Preadmission Screen, also known as the DMS-787, with a completion date of 05/17/2024, revealed Resident #1 had a diagnosable major mental disorder indicated as panic or other severe anxiety disorder. A review of Resident #1 ' s hospital records dated 05/20/204 revealed, Resident #1 became very angry when wound care was attempted, screamed out in pain, and yelled Everybody leave the room right now! I am tired of everyone hurting me! When staff attempted to clean stool off, Resident #1 responded I don ' t care, just leave me alone! Hospital records also indicated chronic narcotic use for pain related to multiple joint arthritis especially of the hips and knees, bed bound mobility since November 2023, a risk for falls related to behavior with interventions including appropriate de-escalation techniques, diversion activities, and a sitter, a coping problem possibly related to grieving, lack or control, altered self-image, depression, noncompliance, or impaired social functioning. A review of a hospital record, with a printed date of 05/20/2024, revealed social determinants of health included social isolation. Plan revealed treatment of chronic sacral decubitus ulcer. A review of the Admission Agreement, signed by Resident #1 on 05/20/2024, revealed due diligence would be used by the facility to obtain the services of a physician when the resident ' s condition requires such medical attention and would attempt to obtain the services of another physician if resident ' s personal physician was unavailable. Further, the facility would obtain, at the discretion of the physician or the facility, ancillary services, such as physician or ambulance services, deemed necessary for the health and welfare of the resident. A review of the Acknowledgment of Receipt of Advanced Directive Information-Resident, signed by Resident #1 on 05/20/2024 indicated, Resident #1 chose to have continued administration of all possible medical treatment, as ordered by the physician, to prolong life to the greatest extent possible without regard to condition, chance of recovery, or expense. A review of the Capacity Verification, dated 05/20/2024 did not indicate a capacity (an individual ' s mental or physical ability) and was signed by the resident and an unidentified facility representative. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/27/2024, revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #1 ' s mood interview was reported as no symptoms present for little interest or pleasure in doing things and feeling down, depressed, or hopeless. Resident #1 was reported to have no behavioral symptoms physical, verbal, or otherwise and no behaviors of refusal of care. A stage 4 pressure ulcer was identified that was present on admission and Resident #1 was at risk of developing pressure ulcers. Skin and ulcer treatments identified were pressure reducing device for the chair, pressure reducing device for the bed, and ulcer care. A review of Resident #1 ' s Care Plan, last modified on 10/25/2024, revealed Resident #1 became agitated and distressed when out of bed due to pain, self-directed activities like television programs, writing letters, balloon toss, Bible reading, inspirational music were initiated with activities to boost Resident #1 ' s self-esteem. The goals included making eye contact, making a verbal response, reaching for items, smiling, and engaging in activities. Resident #1 had a self-care deficit related to pain and refused wound care interventions, skin assessments, urinary catheter care, bowel incontinence care, and turning. Interventions included assistance of two staff members for bathing and turning, and staff was to inspect skin for redness, open areas, scratches, cuts, and bruises. The goal was for Resident #1 to maintain current level of care. Resident #1 was care planned for an antidepressant for mood disorder interventions included an antidepressant with a black box warning to caregivers for appropriate monitoring and close observation for clinical worsening, suicidality, or unusual changes in behavior. Resident #1 was only care planned for behavioral health interventions of medication and no counseling or therapy sessions. Resident #1 had a wound infestation (maggots) related to refusal of wound care. Resident #1 had contact isolation due to wound and wound myiasis (a parasitic infection that occurs when fly larvae [maggots] burrow into the skin of a live animal and feed on its tissue) related to refusal of wound care. Interventions included pest control with a fly light trap, treatment of myiasis as ordered by physician, and wound care as ordered by physician, resident refused. Resident #1 was on narcotic pain medication therapy. Interventions included narcotic pain administration as ordered and monitor for respiratory side effects; the goal was Resident #1 will be free from any discomfort or adverse side effects from pain medication. A review of Order Summary Report, with active diagnoses as of 10/01/024, revealed Resident #1 had a pain assessment every shift with a start date of 05/20/2024; treatment of coccyx wound daily and as needed with a start date of 05/23/2024; an antidepressant daily for mood affective disorder, with a start date of 05/21/2024; oral opioid pain medication every 4 hours as needed for severe pain with a start date of 07/26/2024; an opioid pain medication every 4 hours as needed for pain; an antidepressant at bedtime for mood affective disorder, with a start date of 05/20/2024. A review of the Nsg [Nursing] Admit/Readmit/Quarterly Assessment, dated 05/20/2024 revealed a skin assessment integrity comment, Stage four noted to resident ' s coccyx with wet to dry treatment in place. Sensory Perception indicated Resident #1 ' s ability to meaningfully respond to pressure related discomfort was slightly limited, was able to respond to verbal commands, cannot always communicate discomfort or the need to be turned OR has some sensory impairment limiting the ability to feel pain or discomfort in 1 or 2 extremities. Resident was bedfast and had very limited mobility and was unable to make changes independently and was at moderate risk for dehydration. Cognition did not identify current psychiatric diagnoses or behavioral problem. Neurological assessment indicated resident was alert and oriented to person, place, time, and situation and was verbally appropriate. Resident #1 indicated pain occurred frequently in the last 5 days effecting sleep and day to day activities, and current pain was severe and rated it a 10 on scale of 0-10. No behaviors were documented. A review of a Progress Note on 05/20/2024 at 4:42 PM, revealed Resident #1 was admitted via stretcher from the hospital. Resident #1 refused to allow staff to perform a skin assessment stating they only wanted to be changed once a day and would not allow staff to perform anything else. Former-Assistant Direct of Nursing (F-ADON) was made aware and after encouragement the resident allowed a limited viewing. On 05/22/2024 at 4:07 PM, there were multiple attempts to complete the admission skin audit were refused by Resident #1. The hospital reported at time of discharge Resident #1 had a stage 4 pressure ulcer to the coccyx and a Deep Tissue Injury (DTI) to the right calf. A review of a Progress Note dated 05/23/2024 at 11:22 AM revealed, the floor nurse and APRN #4 attempted wound assessments. Resident #1 refused care, stating they only get turned once a day because they can ' t turn more than once, and it would be after they had a bowel movement. APRN #4 reviewed hospital records and noted refusal of care history. No new or alternative interventions were offered to Resident #1 ' s refusal. A review of a Progress Note dated 05/23/2024 at 2:04 PM revealed, the F-ADON attempted multiple times with staff to provide wound care. It was stated Resident is own responsible party. No new or alternative interventions were offered to Resident #1 ' s refusal. A review of a Progress Note dated 05/26/2024 at 1:20 AM revealed, Resident #1 ' s chronic opioid pain medication was stopped, floor nurse reported no agitation or anxiety just refusal of care. A review of a Progress Note dated 05/26/2024 at 1:12 PM revealed, Resident #1 called nurse into the room to discuss a plan for staff care. Resident #1 stated while in the hospital a pain pill would be provided and 45 mins later, they would call the nurse to provide peri care and wound care at the same time. Resident #1 only wanted to turn once a day. Resident #1 was informed the chronic opioid pain pill had been stopped yesterday and there were no current orders, nurse stated they would contact the provider. A review of a progress note dated 05/26/2024 at 2:08 PM revealed, a new order had been placed for a replacement opioid pain medication, but not Resident #1 ' s chronic opioid pain medication. A review of a progress note, dated 05/26/2024 at 11:43 PM, revealed Resident #1 stated they did not allow day shift to provide wound care due to pain. Resident #1 suggested the nurse complete it after medication pass, but later stated they were going to bed. No alternative interventions were offered to Resident #1 ' s refusal. A review of a progress note, dated 05/28/2024 at 6:33 PM, revealed Resident #1 refused all wound care after medicated twice with replacement opioid pain medication stating it was still too painful. No alternative interventions were offered to Resident #1 ' s refusal. A review of a progress note, dated 05/29/2024 at 5:26 PM, revealed the charge nurse reported to management an odor in Resident #1 ' s room suspected causes was the Resident ' s wound. Resident #1 was medicated with replacement opioid pain medication prior, then staff attempted to perform incontinence care and wound care. Resident # 1 agreed but started to complain of pain while on their left side and requested to be left alone. Resident #1 was advised of feces still on their body and the wound and the risk of refusal could lead to infection and sepsis. Resident # 1 was advised they need to roll on the right side and stated, due to the pain they would rather lie in feces than be rolled. Resident #1 refused care without any alternative pain medication or anti-anxiety medication offered. Former-Director of Nursing (F-DON), Administrator, and APRN notified. It was stated Resident was their own responsible party. A review of a progress note, dated 05/30/2024 at 4:43 PM, revealed Resident #1 refused wound assessment, wound care, and incontinence care by nurse and APRN, cited as too painful to even move and stated, I would rather die, than to let you move me. Risk of infection and death explained and Resident #1 verbalized understanding. No alternative intervention, no anti-anxiety medication offered to Resident #1 ' s refusal. A review of a progress note, dated 06/02/2024 at 3:20 PM, revealed Resident #1 allowed staff to pull them up in the bed but screamed and said it hurt. Resident #1 continued to refuse incontinence and wound care, stating it ' s too painful. A review of a progress note, dated 06/03/2024 at 3:20 PM, revealed Social Services Director (SSD), F-DON, and APRN held a care plan meeting at Resident #1 ' s bedside. Resident #1 stated such unbearable pain with attempts to roll, F-DON advised the wound needed to be cleaned to help with infection. Resident #1 verbalized understanding but stated they couldn ' t handle the pain. Resident #1 stated replacement narcotic pain medication helped with soreness but didn ' t come close to touching the pain in their hips and knees when rolling. APRN discussed other possible medications and methods, Resident #1 stated they were open to trying something different. A review of Resident #1 ' s June Medication Administration Record (MAR) revealed a new order for a transdermal opioid pain patch was started on 06/04/2024 at 8:00 AM. A review of a progress note, dated 06/06/2024 at 11:37 AM, revealed Resident #1 continued to refuse all care including bathing, incontinence care, and wound care stated it was too difficult and painful to roll back and forth. Staff offered a mechanical lift; Resident #1 stated it was too painful as well. A review of a progress note, dated 06/07/2024 at 3:15 PM, revealed the SSD contacted the Regional Ombudsman to help facilitate care with Resident #1. SSD stated the facility was looking at issuing a 30-day discharge notice. A review of a progress note, dated 06/07/2024 at 6:39 PM, revealed Resident #1 continued to refuse all incontinence care and personal care related to pain management. Resident continued complaint of pain which interferes with activities of daily living (ADL ' s), personal care, and inability to turn for wound care. Resident #1 became angry with bedside nursing staff and threw the diner tray down. Resident #1 stated I hate this [expletive] place and the people here, [pronoun] hurts too much to turn, and Resident #1 stated they would need to be put out to have wound care performed. APRN aware of Resident #1 ' s continued refusal of care. Resident is own responsible party was documented. No alternative intervention offered, no alternative plan of care for surgical wound debridement under anesthesia suggested, no anti-anxiety medication offered, no escalation to Medical Director, or visit from the Administrator. A review of a progress note, dated 06/17/2024 at 10:23 AM, revealed Resident #1 was laying in feces and refused to allow staff to roll them and provide care. Resident #1 stated its too painful and what ' s the point anyway. No alternate pain medication or route was sought out, no anti-anxiety medication was offered, the Medical Director was not contacted, and the Administrator did not attempt to assist with the resident. A review of a progress note, dated 06/17/2024 at 1:14 PM, revealed Resident #1 continued to refuse care related to pain from osteoarthritis. Resident #1 reported increased pain since hospitalization in November, the new order for (Name Brand) opioid transdermal pain patch was not helping. Resident #1 reported none of the pain medications were helping the pain. Resident #1 was told if they continued to refuse care other housing options would be sought out. Resident #1 stated they liked the facility and did not wish to leave, then became upset, didn ' t want to finish the conversation, and asked to be left alone. A review of Primary Care Physician (PCP) ' s 06/17/2024 visit note revealed, Resident #1 ' s Mood was stable without behavioral problems noted antidepressant medication was continued with no change, the facility had not been able to assess the wound related to resident refusals, education was provided on wound care, options of comfort care measures, or transferring facilities were offered to Resident #1. No indication of intravenous (IV) pain medication, no anti-anxiety medication, no surgical consult for wound debridement under anesthesia or consult to the Medical Director was noted. Resident #1 reported to PCP the (Name Brand) opioid transdermal pain patch was not touching his pain. A review of a progress note, dated 06/17/2024 at 2:41 PM, revealed Resident #1 ' s replacement opioid pain medication was increased. A review of a progress note, dated 06/17/2024 at 2:42 PM, revealed Resident #1 ' s (Name Brand) opioid transdermal pain patch was increased. A review of a progress note, dated 06/18/2024 at 10:21 AM, revealed Resident #1 told the Regional Ombudsman they liked the facility and refused care related to chronic pain issues. Ombudsman indicated with continued refusal a new placement, or a discharge would happen. No alternative approach or intervention was indicated. A review of a progress note, dated 06/21/2024 at 00:47 AM, revealed Resident #1 continued to refuse care, and when asked to rate their pain, indicated it was fine and not the problem the nurse should be concerned about. No other problem was identified by the resident, no further investigation was done by staff to find out, no counselor was consulted, and the medical director was not notified. A review of a progress note, dated 06/21/2024 at 12:54 PM, revealed the nurse offered Resident #1 an unscheduled pain pill to premedicate for wound care. Resident #1 responded by lowering their eyes and voice and stated, I ' m perfectly fine right now. Before the nurse could get a response out Resident #1 with eyes closed and head down, held their hand up and repeated, I ' m perfectly fine right now. A review of a progress note, dated 06/21/2024 at 3:27 PM, revealed Resident #1 ' s room had a smell indicating they had a bowel movement. Resident #1 refused attempted to remove the soiled brief, assess their skin, change them, or provide pain medication. Resident #1 would dismiss staff from room when something disagreeable is said. A review of a progress note, dated 06/22/2024 at 10:48 AM, revealed a foul odor was observed in Resident #1 ' s room and the sitting area outside the room. The nurse attempted to provide an extra pain medication, and to attempt wound care. Resident #1 closed their eyes, held up their hand, and stated, Why would you think we are doing it this afternoon?! I ' ve told you people until I ' m blue in the face, I will have to be unconscious for that! What does it take to get through?! Nurse educated Resident #1 on infection risk and sepsis from sitting in stool. Resident #1 responded, I know, [Nurse Name], I know. And I ' m not dealing with the pain, I ' ve already told you. The Medical Director was not made aware of the situation or the Resident #1 ' s request, the Administrator did not engage in any communication with the resident, and no surgical consult was attempted for wound debridement under anesthesia, no anti-anxiety medication was suggested. A review of a progress note dated 06/23/2024 at 1:11 PM revealed, Resident #1 had a bowel movement, was sitting in it, and refused care from staff. The nurse reported Resident #1 Shuts down when staff attempt to provide care. Resident closes eyes as if to ignore us and would dismiss staff from room when they disagreed or became frustrated. The Medical Director was not made aware of the situation or the Resident #1 ' s request, the Administrator did not engage in any communication with the resident, and no surgical consult was attempted for wound debridement under anesthesia, no anti-anxiety medication was suggested. A review of PCP ' s 06/26/2024 at 2:22 PM visit note revealed Resident #1 antidepressant medication was continued with no change, the facility had not been able to assess the wound related to resident refusals, education was provided on wound care, options of comfort care measures, or transferring facilities were offered to Resident #1. Resident #1 was indicated to have degenerative joint disease in multiple sites and refusing to turn for incontinence care or wound care related to pain, plan was continued replacement opioid pain medication as ordered. A depression assessment tool was used to assess Resident #1 for depression results were as follows; Resident #1 indicated feeling little interest or pleasure in doing things several days a week, feeling down, depressed or hopeless several days a week, feeling tired or having little energy several days a week, poor appetite or overeating several days a week, feeling bad about yourself or that you are failure or have let down your family several days a week, trouble concentrating on things, such as reading the newspaper or watching television several days a week, moving or speaking so slowly that other people could have noticed or so fidgety or restless that you have been moving a lot more, several days a week. Resident #1 indicated several days a week these problems made it difficult to do work, take care of things at home, or get along with other people. Resident #1 responded not at all to thoughts that you would be better off dead, or thoughts of hurting yourself in some way. The depression score was 9. Results were changed from Resident #1 ' s MDS admission assessment 30 days ago which had a 0 depression score identified. A review of a document titled (Medical Group Clinic), Patient consent for Care Management Services signed and dated by Resident #1 on 05/20/2024 indicated, Resident #1 signature agreed to services by the facility employed medical group which included consulting with relevant specialist about your health care . (Medical Group Clinic) will continue to be your primary care provider and will coordinate your care with other providers. A review of a progress note dated 06/26/2024 at 3:15 PM revealed, nurse advised Resident #1 their Primary Care Physician (PCP) was in the facility and wanted complete a wound assessment and send the resident to the emergency room (ER) for evaluation and treatment. Resident #1 was sitting in stool complained of a stomachache, refused care from staff, refused wound assessment from the PCP, and refused transfer to the ER. A review of the Order Summary Report, of discontinued orders, with an order date of 06/26/2024, revealed a psych referral, for 1 day, one time only for refusing care. The end date was 06/27/2024, the order status was completed. No follow through of this order. Resident #1 did not see anyone until second order was placed by APRN #11 on 07/07/2024. A review of a progress note, dated 06/27/2024 at 8:10 AM, revealed PCP discontinued Resident #1 ' s (Name Brand) opioid transdermal pain patch per the resident ' s request and ordered a consult to pain management. A review of the document Informed Consent to Refuse Treatment and/or Services dated 06/26/2024 at 2:53 PM indicated, the facility had offered Resident #1 daily wound care to the coccyx, repositioning, incontinence care, bathing, skin and wounds assessments, body audits, bariatric bed, specialty mattress, and a trapeze bar. The treatments and services were recommended for Resident #1 health and well-being and benefits included wound healing, achieving/maintaining good skin integrity, preventing/decreasing chances of pneumonia, deep view thrombosis, more wounds, infection, and possible death. Risk that might be reasonably expected as a result of refusing treatment and services included worsening of wound with new wounds, pneumonia, deep vein thrombosis, infection, sepsis, and even death could occur. The document is signed by Resident #1, witnessed by the F-ADON, and signed by the PCP. The Medical Director was not aware and did not sign, the Administrator did not sign, and no noted conversation was had regarding the resident ' s new depression symptoms, no surgical consult was attempted for wound debridement under anesthesia, no anti-anxiety medication was suggested. A review of Resident #1 ' s Admission Record from 05/20/2024 indicated 06/26/2024 was Resident #1 ' s 57th Birthday. No notation was made, no notes from the Activity Director or SSD, no indication the facility noticed. A review of a progress note, dated 06/28/24 at 3:24 AM, revealed Resident #1 had the (Name Brand) narcotic transdermal pain patch discontinued because they wanted to look at other means of pain control. Resident continued to take all medications and was tolerating well. A review of a progress note dated 06/29/2024 at 7:55 AM, stated, Advised nurse to try to determine reason for rejection of care. Determine if changes need to be made for those that are providing care such as have male aides working with the resident during care. Modify the plan of care. No indication of any findings or modified interventions noted, no suggestions for anti-anxiety medication, no counseling suggested, no contact to the Medical Director, and no visit from the administrator was made. A review of a (Medical Group) note, dated 07/03/2024 at 12:52 PM, revealed Resident #1 was seen by APRN #11, findings included a history of obesity (02/19/2024), anxiety (03/25/2024), panic disorder with agoraphobia (a fear of places and situations that might cause panic, helplessness, or embarrassment) (02/19/2024), depressive disorder (02/19/2024), insomnia (05/21/2024), chronic pain (02/16/2024), pressure injury of the buttock (02/28/2024), unstageable pressure injury (05/23/2024), muscle weakness (02/19/2024), open wound of the buttocks with complications (03/29/2024) pain in the right hip joint (03/21/2024). Resident #1 refused to allow staff to turn them, had a wound and refuses wound APRN to assess related to pain and the pain medication had been changed. There have been no changes to Resident #1 ' s psychotropic medications. Resident #1 had pain and pain medication were ordered. It was reported a recent workup had been performed to rule out medical delirium, but the description of the workup, test results, and the diagnosis was left blank. Review of symptoms (ROS) Resident #1 reported exercise intolerance, muscle weaknes [TRUNCATED]

Based on interview and record review, the facility failed to ensure a newly admitted resident, who continued to refuse activity of daily living (ADL) care and assistance, and assessment and treatment for pressure wounds, and all available remedies were provided to ensure the resident's mental and psychosocial health did not continue to deteriorate for 1 (Resident #1) of 8 residents reviewed for mental and psychosocial health, as evidenced by the failure to ensure a newly admitted resident's wounds were assessed, monitored, and treated to prevent death. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.40 (Behavioral Health) at a scope and severity of J. The IJ began on [DATE], when Resident #1 began refusing wound care, and the facility failed to provide effective interventions to alleviate declines in the resident's mental and psychosocial health that would potentially allow staff to provide needed care. The Administrator and Nurse Consultants were notified of the IJ on [DATE] at 9:56 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on [DATE] at 9:13 PM. The IJ was removed on [DATE] at 5:30 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Findings include: A review of a facility policy titled, Resident Rights, revised on [DATE], indicated facility staff were trained on resident rights and involved in the implementation of the policy and procedure. Residents have a right to be informed of their health, medical condition and treatment, participate in or refuse treatment, be advised of alternative care and treatments and their consequences. Residents have the right to 15. Receive adequate and appropriate medical care, nursing care, protective and support services, and personal cleanliness in a safe and clean environment. 22. Be transferred or discharged on ly for medical reasons, for your welfare or that of others . 33. Be free from physical abuse and neglect . On [DATE] at 12:25 PM, the Administrator stated the facility did not have a policy for wound care, the Medical Director was an independent contractor, and the facility does not have a job description for the Medical Director. Review of the job description for Administrator described the position was to manage and direct the day-to-day operations of the facility, learn and implement state and federal regulations. Responsibilities of the position included resident safety, reviews complaints and grievances, maintain written policies and procedures, assist department head with eliminating and correcting problem areas. Review of the job description for the Director of Nursing (DON) described the position responsibilities included assuring resident safety, day to day operation and management of the nursing department and working closely with the Administrator regarding coordination of resident services and functions of the nursing department. Review of the job description for the Assistant Director of Nursing (ADON) described the position responsibilities included assuring resident safety and day-to-day operations of the nursing department, meeting with team members regarding coordination of resident services. Review of the job description for the Charge Nurse described the position responsibilities included assuring resident safety; perform nursing services for the comfort and well-being of the residents; check residents daily to determine status, assess, record, and report changes in residents' condition to supervisor and attending physician; complete treatment orders; complete skin audits; identify nursing problems and respond and initiate immediate action; communicate problems to DON; provide emergency care to residents; assess resident needs and provide input for care. Review of the job description for the Treatment Nurse described the position responsibilities included assuring resident safety; completing treatment orders; assist and complete skin audits; safety of residents; identify safety hazards and special nursing problems and initiate immediate action; communicate problems and needs in nursing department; assess and report changes in resident condition and take follow-up action as necessary; provide emergency care to residents; assess resident's needs and provide input. Review of the job description for Certified Nursing Assistant (CNA) described the position responsibilities included assuring resident safety; identify resident problems and concerns and report them immediately to charge nurse or a licensed nurse; report changes in residents' condition. A review of the Medical Director Retainer Agreement with an effective date [DATE] described, the duties of the Medical Director included guidance and oversite in the development and implementation of resident care policies that reflect current standards of practice; responsible for coordination of medical care in the facility; identifying, evaluating, and resolving medical and clinical concerns and issues affecting resident care, medical care or quality of life or were related to the provision of services by physicians and other licensed health care practitioners. Medical care through medical doctors, Advanced Practice Registered Nurse (APRN)'s, and telehealth services provided by the contracted provider limited liability company. A review of the medical director statement, provided by the Administrator, dated [DATE], described the physician designated as the Medical Director, was not the physician named as the Medical Director in the Medical Director Retainer Agreement, as the agreement was between the limited liability company and the facility and not with the individual provider. A review of the Admission Assessment Communication, dated [DATE], revealed Resident #1 was a hospital referral for possible long-term care (LTC) placement. Nursing information included Resident #1 required maximum assistance of two for rolling over in bed and moving from a laying to sitting position; required assistance with oral hygiene; maximum assistance toileting and perineal care, and was incontinent at times; mechanical lift for transfers and no restrictions on ambulation; cognitive status was alert and oriented; had a sacral decubitus ulcer (pressure ulcers that appear on the skin over a bony region of the spine called the sacrum); required a wheelchair; had a mood disorder and was receiving medication. A review of the Level I Preadmission Screen, also known as the CMS-787, with a completion date of [DATE], indicated Resident #1 had a diagnosable major mental disorder indicated as panic or other severe anxiety disorder. A review of the Report of Disability Examination, also known as the DCO-0107S, with a signed date of [DATE], indicated a medical history that included severe morbid obesity, unspecified mood disorder, and chronic pain. Pain with movement classified as 10 on a scale of ,d+[DATE], 10 being the worst. Medications listed included a serotonin reuptake inhibitor (antidepressant), a selective serotonin reuptake inhibitor (antidepressant), two antihypertensives, a skeletal muscle relaxant, oral opioid, opioid analgesic patch, and three medications for elevated blood sugar. A check box response to the question, Has the patient followed treatment recommendations? was No. Comments indicated Multiple instances - refusal of Care. A review of the Medical Review Team (MRT) Social Report for Adults, also known as the DCO-0108S, with an application date of [DATE] indicated Resident #1's illness, injury, or conditions limiting ability to work or perform household activities included, chronic pain described as constant pain with treatment that included wound care and pain medication. MD #1 and APRN #11 were listed as physicians seen by Resident #1 in the past year, and Resident #1 was hospitalized from [DATE] to [DATE]. A review of the Hospital Medical Discharge Summary, with a discharge date d of [DATE], indicated Resident #1 had morbid obesity, was chronically bedbound related to deconditioning and not moving much, implanted catheter, poor social living scenario, and chronic pain. A note dated ,d+[DATE] indicated resident continued to refuse physical therapy and turning and there was a high concern for continued decline with refusal to comply. A note on ,d+[DATE]-,d+[DATE] indicated Resident #1 had not been compliant with any activity. Instructions included wound care to peri and gluteal area. A review of the Admission Agreement, signed by Resident #1 on [DATE], indicated due diligence would be used by the facility to obtain the services of a physician when the resident's condition requires such medical attention and would attempt to obtain the services of another physician if resident's personal physician was unavailable. Further, the facility would obtain, at the discretion of the physician or the facility, ancillary services, such as physician or ambulance services, deemed necessary for the health and welfare of the resident. A review of the Acknowledgment of Receipt of Advanced Directive Information-Resident, signed by Resident #1 on [DATE] indicated, Resident #1 chose to have continued administration of all possible medical treatment, as ordered by the physician, to prolong life to the greatest extent possible without regard to condition, chance of recovery, or expense. A review of the Capacity Verification, dated [DATE] did not indicate a capacity and was signed by the resident and an unidentified facility representative. A review of the Admission Record, indicated the facility admitted Resident #1 on [DATE] with diagnoses that included pressure ulcer of the sacral region, Type 2 diabetes mellitus, malaise, morbid obesity, mood affective disorder, and chronic pain. A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], indicated Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #1's cognitive patterns for the BIMS score were based on the ability to repeat three words on first attempt; correct response to the current year; correct response to the current month, within five days; correctly identify the day of the week; and recall the words sock, blue, and bed with no cueing. Resident #1's mood interview, sections C through I were not completed related to negative symptom responses to the first two questions, and a total severity score indicated 00. Social isolation indicated Never. Section E - Behavior indicated Resident #1 had no physical, verbal, or other behavioral symptoms that included self-injury, throwing or smearing food or bodily wastes, and verbal/vocal symptoms. No refusal of care was indicated. Resident #1 indicated it was very important to take care of personal belongings, choose type of bathing, choose bedtime, have family or a close friend involved in discussions about care, have reading materials, listen to music, and go outside for fresh air. Resident #1 had impairment of bilateral lower extremities, used a wheelchair for mobility, was dependent on staff for toileting and dressing; required substantial/maximal assistance with oral hygiene and personal hygiene; required setup/cleanup assistance with eating; and refused shower/bathing self. Resident #1 was dependent on staff to roll left and right, refused to sit up, refused to transfer to a chair, refused to use wheelchair, and refused to transfer for a tub or shower. Resident #1 had an indwelling catheter and was continent of bowel. Active diagnoses were identified as diabetes mellitus, morbid obesity, mood affective disorder, and chronic pain described as occurring frequently and not interfering with daily activities. Prognoses of life expectancy of less than 6 months indicated no. Skin condition indicated a stage IV pressure ulcer (most severe stage, significant tissue loss, damage extends through all layers of skin exposing muscle, tendon/bone, high risk of infection) was present on admission and Resident #1 was at risk of developing pressure ulcers. Resident #1 medications received included an antidepressant and opioid. Resident #1 had a goal to remain in the facility and not return to the community. Care areas identified included activities of daily living (ADL) functional/rehabilitation potential; urinary incontinence and indwelling catheter; falls; nutritional status; dehydration/fluid maintenance; pressure ulcer; psychotropic drug use; and pain. A review of the significant change MDS, with an ARD of [DATE], indicated changes from the admission MDS included the following: Resident #1 exhibited behavior described as worsening for rejection of care occurring daily. Resident #1 refused shower/bathe, dressing, rolling left or right in bed, and any transferring; required supervision with oral hygiene. Resident #1 was always incontinent of bowel. Pain was described as effecting sleep, interfering with therapy activities, and day to day activities almost constantly, and rated as a 10 on a scale of ,d+[DATE] with 10 being the worst pain imagined. Resident #1 did not receive scheduled pain medication. Medications included an antibiotic. Care areas identified included cognitive loss/dementia and behavioral symptoms. A review of Resident #1's care plan with a resolved date of [DATE], indicated Resident #1's code status as full code, wanting cardiopulmonary resuscitation. Interventions included providing the opportunity for resident to discuss feelings and ask questions related to end of life decisions and review code status; and a change in code status to do not resuscitate (DNR) with interventions that included checking for resident signature on consent form; verify physician order; review code status with resident annually and as needed; acknowledge right to revoke DNR status; and a. Resident #1 had contact isolation due to wound and wound myiasis (a parasitic infection that occurs when fly larvae [maggots] burrow into the skin of a live animal and feed on its tissue) related to refusal of wound care. Interventions included pest control with a fly light trap, treatment of myiasis as ordered by physician, and wound care as ordered by physician resident refused; and b. Resident #1 had an ADL self-care performance deficit related to chronic pain, refusing ADL care, turning, wound treatment, incontinent care and catheter care. Interventions included, resident was totally dependent on 2 staff for bathing/showering, mobility, dressing, toileting, transferring with mechanical lift, was bedfast, used bedrails for independence with turning and positioning, dependent on 1 staff for personal and oral hygiene, required skin inspection and was to be observed for redness, open areas, scratches, cuts, bruises and report changes to nurse; and c. Resident #1 exhibited behaviors that included rejection of care with interventions that included providing staff training on behaviors, notification to the physician of changes in behavior, and administering and monitoring effectiveness of medications; and d. Resident #1 was resistant to care evidenced by refusal of care, to be repositioned, refused skin assessments and treatments. Interventions included allowing Resident #1 to make decisions about treatment to provide sense of control, educate on outcome of non-compliance, encourage participation during care activities, clearly explain care activities prior to contact, negotiate ADL care times to allow resident participation, change approach if Resident #1 becomes agitated and notify charge nurse of situation; and e. Resident #1 had no impaired cognitive function/dementia based on BIMS score of 15, would remain oriented to person, place, situation and time, and would maintain current level of decision-making ability. Interventions included engaging in pleasant topic conversation prior to initiating care; and f. Resident #1 was receiving opioid pain medication therapy with interventions that included administering medication as ordered by physician and monitoring side effects of the medication; and g. Resident #1 had antidepressant medications related to affective mood disorder with interventions that included administering medications as ordered and monitoring side effects and effectiveness every shift. A black box medication warning indicated observation and monitoring for suicidality, unusual changes in behaviors, and clinical worsening; and h. Resident #1 had a mood problem related to mood affective disorder with interventions that included behavioral health consults, monitoring for irritability, mood changes, and agitation; and i. Resident #1 had chronic pain with interventions to anticipate need for pain relief, evaluate effectiveness of interventions, monitor for non-verbal pain, mood/behavior changes and review impact on functional ability and impact on cognition; and j. Resident #1 had a pressure ulcer to coccyx/sacrum and potential for development of pressure ulcers and refused treatment that included wound care, turning and repositioning, wound assessments per protocol and full skin assessments. Goals included healing of the pressure ulcer, remain free of infection, and maintain or develop clean intact skin. Interventions included administration of medication and treatments as ordered, educating resident on causes of breakdown and frequent positioning; and k. Resident #1 had an indwelling catheter. Interventions included changing catheter as ordered, resident refused catheter changes and care; monitor and report signs and symptoms of urinary tract infection, that included foul smelling urine, altered mental status, change in behavior. Resident #1 refused a follow up urology appointment. A review of Order Summary Report, with active orders as of [DATE], indicated Resident #1 had a pain assessment every shift with a start date of [DATE]; treatment of coccyx wound daily and as needed with a start date of [DATE]; an antidepressant daily for mood affective disorder, with a start date of [DATE]; oral opioid pain medication every 4 hours as needed for severe pain with a start date of [DATE]; an opioid pain medication every 4 hours as needed for pain; an antidepressant at bedtime for mood affective disorder, with a start date of [DATE]. A review of the Order Summary Report, of discontinued orders, with an order date of [DATE], indicated a psych referral, for 1 day, one time only for refusing care. The end date was [DATE], the order status was completed. A review of the Order Summary Report, of discontinued orders, with an order date of [DATE], indicated a referral to mental health clinic for depression, one time only for 4 days. The end date was [DATE], the order status was completed. A review of the Order Summary Report, of discontinued orders, with an order date of [DATE], indicated an antiparasitic medication, 4 tablets by mouth one time a day for 3 days related to wound myiasis. The end date was [DATE], the order status was completed. A review of the Nsg (Nursing) Admit/Readmit/Quarterly Assessment, dated [DATE] indicated a skin assessment integrity comment, Stage four noted to residents (sic) coccyx with wet to dry treatment in place. Sensory Perception indicated Resident #1's ability to meaningfully respond to pressure related discomfort was slightly limited, was able to respond to verbal commands, cannot always communicate discomfort or the need to be turned OR has some sensory impairment limiting the ability to feel pain or discomfort in 1 or 2 extremities. Resident was bedfast and had very limited mobility and was unable to make changes independently and was at moderate risk for dehydration. Cognition did not identify current psychiatric diagnoses or behavioral problem. Neurological assessment indicated resident was alert and oriented to person, place, time, and situation and was verbally appropriate. Resident #1 indicated pain occurred frequently in the last 5 days affecting sleep and day to day activities, and current pain was severe and rated it a 10 on scale of ,d+[DATE]. No behaviors were documented. A review of the Nsg Admit Skin Audit, dated [DATE] indicated Resident #1 had bruising to right and left antecubital areas related to IV (intravenous needle) sticks, dry skin, and a stage 4 wound to coccyx. A review of the Nsg Functional Abilities and Goals-Admission, with an effective date of [DATE] indicated Resident #1 had bilateral lower extremity impairment, required a wheelchair for mobility and was dependent for manual wheelchair use, required substantial/maximal assistance with personal hygiene, was dependent for toileting, dressing, rolling left and right, sitting to lying, lying to sitting, transferring from chair to bed and bed to chair, refused to stand from seated position, and refused shower/bathing. A review of the Nsg Functional Abilities and Goals-Interim, with an effective date of [DATE] indicated Resident #1 had no functional impairment of the upper extremities, had bilateral impairment of the lower extremities, utilized no devices for mobility, required substantial/maximal assistance with personal hygiene, was dependent with toileting hygiene, and refused shower/bathing, dressing, mobility that included rolling left and right, sit to lying and lying to sitting on side of bed, sit to standing, chair to bed and bed to chair transfer, toilet transfer, tub/shower transfer, was not assessed for walking or use of wheelchair. A review of Medication Administration Record (MAR), for [DATE] ([DATE] through [DATE]) indicated Resident #1 had pain documented 9 times above a level of 0, with medication administered. A review of Treatment Administration Record (TAR), for [DATE] indicated Resident #1 refused to allow wound care [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. No as needed (PRN) wound care was documented. A review of MAR, for [DATE] indicated Resident #1 had an opioid transdermal patch applied [DATE] every 72 hours with a dosing change on [DATE]. Refused urinary catheter to be changed on [DATE]. Refused weekly weight on [DATE], [DATE], and [DATE]. Pain was assessed 24 times above a level of 0, with medication administered. A review of TAR, for [DATE] indicated Resident #1 refused wound care 29 days. No PRN wound care was documented. Psych referral was documented as done on [DATE]. A review of MAR, for [DATE] indicated Resident #1 had pain was assessed 14 times above a level of 0, with medication administered. A review of TAR, for [DATE] indicated Resident #1 refused wound care 30 days. No PRN wound care was documented. A review of MAR, [DATE] indicated Resident #1 refused urinary catheter to be changed on [DATE], antiparasitic tablets administered on [DATE], [DATE], and [DATE]; was received a diuretic daily for fluid overload on [DATE] through [DATE]. Pain was assessed 20 times above a level of 0, with medication given. An antibiotic was administered three times a day for 7 days for wound myiasis. A review of TAR, [DATE] indicated Resident #1 refused wound care to coccyx for 31 days and had a new order for wound care on bilateral lower extremities and refused care. No PRN wound care was documented. A review of MAR, [DATE] indicated Resident #1 had catheter changed however, progress notes documented refusal of care and did not address the catheter. Pain was assessed 25 times above the level of 0, medication was not administered 5 times for pain levels of ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE], due to blood pressure being below 100 systolic. A review of TAR, [DATE] indicated Resident #1 refused wound care to coccyx and wound care to bilateral lower extremities for 30 days. A review of MAR, [DATE] indicated Resident #1 began intermittent refusal of oral medications. Pain was assessed 32 times above the level of 0, with medication administered. A review of TAR, [DATE] indicated Resident #1 refused wound care to coccyx and wound care to bilateral lower extremities for 23 days. On [DATE], Resident #1 was seen by APRN #11 for hospital follow up. Reviewed problems included Type 2 diabetes mellitus (DM), morbid obesity, anxiety, panic disorder with agoraphobia, depressive disorder, chronic pain, pressure injury of buttock, open wound of buttock, and pain in right hip joint. History of present illness (HPI) included Urinary catheter surgically implanted, denies depression. Physical examination indicated morbid obesity and limited ambulation. Psychiatric mental status was normal mood and lethargic; was oriented to time, place, and person. Musculoskeletal indicated limited range of motion (ROM) and right hip pain. Assessment plan included: DM, chronic pain continue opioid; depressive disorder continue antidepressant. Open wound of buttock was not assessed. On [DATE], Resident #1 was seen by APRN #4 for open wound assessment. Reviewed problems included unstageable pressure injury, open wound of buttock with complication, pain right hip joint. HPI included reported stage 4 pressure ulcer to coccyx, present on arrival to facility. Visit was first wound care visit. unable to access Stage 4 pressure ulcer to coccyx and other unknown wounds as patient currently refuses to turn for full body skin assessment. Resident reported due to pain, would turn once per day when goes to the bathroom. Review of system (ROS) indicated unable to assess wounds. Orders given for wound care, if unable to perform tele visit at time of turning. On [DATE], Resident #1 was seen via telemedicine by APRN #22 for report of change in condition, HPI indicated expired opioid order, pressure ulcer required dressing change, and pain at wound site during wound care. ROS included mental status as active and alert. Assessment/Plan was chronic pain with a change in opioid medication. On [DATE], Resident #1 was seen by PCP as new admission. The problem list included morbid obesity, heart failure, DM type 2, hypertension, malaise, mood affective disorder, and chronic pain. HPI included incontinent of bladder, continent of bowel, mood stable without behavioral problems, and was compliant with medications and care. Functional assessment indicated one person assist for ADLs and transfers. ROS included no anxiety or depression. Assessment/Plan included depressive disorder - continue antidepressant, impaired ADLs - assist and monitor, degenerative joint disease (DJD) - continue pain control with opioid, assist with ADLs and monitor, moderate to severe frailty syndrome - bedbound, assist with ADLs and monitor, sarcopenia (muscle loss) - assist with ADLs and monitor, poly-pharmacy - educate on medication interaction/adverse effects and monitor for adverse effects. On [DATE], Resident #1 was seen by APRN #11 for follow-up on chronic pain. HPI indicated follow up for sacral ulcer, refusing bed and incontinence changes, wound care and repositioning related to pain. ROS indicated psychiatric mental status was active and alert and normal mood, oriented to time, place, and person. Assessment/Plan indicated chronic pain, continue oral opioid and PCP ordered opioid transdermal patch. On [DATE], Resident #1 was seen by PCP for acute visit for toenail care. ROS and Exam indicated skin had no rash, itching or skin changes and was warm dry (W/D) and intact. Assessment and plan included pressure ulcer on coccyx - resident does not want to be rolled due to pain. Continue facility wound care and Monitor for infection. DJD indicated staff reporting refusal of care due to pain; resident reports pain in hips, back and bilateral knees, educated on taking medication to stay ahead of pain, resident reported still has pain 40 minutes after taking medication; educated on importance of care compliance; opioid patch ordered for pain. On [DATE], Resident #1 was seen by PCP for acute visit for toenail care. HPI indicated mood stable with no behavioral problems and was compliant with care. Exam included psychiatric evaluation described as calm, cooperative, alert and oriented (AO) x 3 (indicating person, place, situation), and follows commands. Assessment/Plan indicated facility was unable to access wound due to refusal, resident does not want to be rolled. Staff reported refusal of all care. Provided options if continued refusal of care that included comfort care and transfer to another facility. Continue facility wound care. Opioid patch dose increased; oral opioid medication added. On [DATE], Resident #1 was seen by PCP for annual wellness visit. ROS indicated no joint pain, joint swelling, or restricted movements. Psychiatric indicated no anxiety or depression. Physical findings included, psychiatric as calm, cooperative, AOx3, and followed commands. Assessment indicated normal routine history and physical senior citizen (,d+[DATE]). (Resident #1 was [AGE] years old.) A PHQ (patient health questionnaire) -9 score (screening, diagnosing, monitoring, and measuring severity of depression) was performed with a score of 9.0 indicating mild depression. Counseling/Education included nutritional needs, resident verbalized/demonstrated understanding of medical condition and disease process, educated on proper diet, proper use of medications and hygiene. Plan indicated wound had not been assessed due to resident refusal due to pain when rolled, staff reported refusal of all care. Continue facility wound care, monitor for infection, Not knowing what the wound looks like, send to emergency room (ER) for evaluation, referred to psych for evaluation. DJD indicated resident refused care due to pain, refused to allow staff to change after incontinent episode, refused wound care, resident refused PRN medications for pain, stated hurts too much to roll over for care. Opioid patch discontinued. Medication continued for depressive disorder. Review of Informed Consent to Refuse Treatment and /or Services, dated [DATE] indicated Resident #1 signed the informed consent, at 2:53 PM, that outlined the PCP orders for daily wound care to coccyx, turning and repositioning, incontinent care, bathing, skin/wound assessments, body audits, bariatric bed, specialty mattress, and trapeze bar. Resident provided with the benefits and results of refusal up to and including death. Review of a Progress Note, dated [DATE] at 07:55 AM, indicated Resident #1 rejected care and the nurse was advised to try to determine reason care rejected such as staff providing care being changed to male aides and to modify care plan as necessary. On [DATE] Resident #1 was seen by APRN #11 for anxiety. Resident refused repositioning, refused wound care evaluation by APRN care, and stated it was related to severe pain. PCP previously adjusted pain medication. No trends/patterns documented; no pain assessment performed; a Yes response to Has there been a recent workup related to this issue to rule out medical delirium was documented with no response to description of workup or diagnosis. ROS revealed resident had fatigue. Physical exam revealed psychiatric mental status was active and alert and normal mood. Assessment/Plan included depressive disorder, continued antidepressant and referred to mental health clinic. On [DATE] Resident #1 was seen via telemedicine by Psychiatric Mental Health Nurse Practitioner (PMHNP) #20 for staff reported behaviors of refusal of care. HPI contained no documentation regarding anxiety, panic disorder, or depressive disorder. Appearance documented as casually gloomed, good eye contact; mood indicated resident reported doing just fine. Affect was documented as euthymic (optimistic and in control); thought process documented as mostly linear (sequential logical order), [NAME][TRUNCATED]

Based on observations, interviews, and facility document review, it was determined that the facility failed to accurately identify resident verbal, physical, or other self-directed behavior symptoms as potential indicators of mental instability for 1 (Resident #1) of 1 resident reviewed for significant change assessment. The findings include: A review of Resident #1 ' s Admission Record, indicated the facility admitted Resident #1 on 05/20/2024 with diagnoses that included unspecified mood disorder, chronic pain, morbid obesity, malaise, and treatment refusal. Review of the Signification Change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/23/2024, revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. No potential indicators for psychosis were identified, such as hallucinations [the perceptual experiences in the absence of real external sensory stimuli or delusions the misconception or beliefs that are firmly held, contrary to reality.] No verbal behavioral symptoms of threatening, screaming or cursing were identified. No other self-directed behavioral symptoms were identified, stated examples, but not limited to: hitting or scratching self, rummaging, disrobing, throwing or smearing food or body waste, or screaming. As a result of no behavioral symptoms identified, further areas were not assessed for the resident behaviors interfering in; care, risk of significant physical illness or injury, social interactions, risk of injury to others, intruding on others privacy or activity, disruptive care, or the living environment. Resident #1 was identified with rejection of care behaviors occurring daily which interfered with the resident ' s health and well-being. Resident #1's behavior status was identified as worsening from the prior assessments due to the daily rejection of care behaviors. Resident #1's functional mobility revealed dependence requiring the helper to do all the effort for toileting hygiene, substantial/maximum assistance for personal hygiene, and resident refused for bathing, upper body dressing, lower body dressing, rolling left and right, and lying to sitting. A review of Resident #1's Care Plan, last modified on 10/25/2024, revealed Resident #1become agitated and distressed when out of bed due to pain, self-directed activities like television programs, writing letters, balloon toss, Bible reading, inspirational music were initiated with activities to boost Resident #1's self-esteem. The goals included: making eye contact, making a verbal response, reaching for items, smiling, and engaging in activities. Resident #1 had a self-care deficit and refused wound care interventions, skin assessments, urinary catheter care, bowel incontinence care, and turning. Interventions included: assistance of two staff members for bathing and turning, and staff was to inspect skin for redness, open areas, scratches, cuts, and bruises. The goal was for Resident #1 to maintain current level of care. Resident #1 was care planned for an antidepressant for mood disorder interventions which included a (Name Brand) antidepressant with a black box warning to caregivers for appropriate monitoring and close observation for clinical worsening, suicidality, or unusual changes in behavior. Resident #1 was only care planned for behavioral health interventions of medication and no counseling or therapy sessions. Resident #1 had a wound infestation issue related to refusal of wound care. Interventions included pest control measures via a fly light trap and treatment of the wound for fly/magot infestation, the goal was for Resident #1 to allow wound treatment. Review of documents provided revealed, Social Services Director (SSD) graduated with a bachelor's degree in Sociology on 05/07/2022 and completed Social Services Director Training on 03/31/2023. During an interview on 12/11/2024 at 10:14 AM, the SSD stated, the process was to interview the resident one-on-one and look at notes going back two weeks. The SSD stated they had been trained on MDS forms and had training an SSD and completed sections B, C, D, E, and Q of the MDS dated [DATE], used for the significant Change Assessment. A two week look back of the Resident #1's Progress Notes revealed the following charted behaviors: 1.A review of a Progress Note, dated 08/09/2024 at 10:24 PM, revealed Resident #1 continued to refuse care, the room was odorous, and the resident had an obvious need for care. 2.A review of a Progress Note, dated 08/10/2024 at 10:36 PM, revealed Resident #1 had refused personal care three times in the shift, the room was odorous, and Resident #1 had an obvious need for care. 3.A review of a Progress Note, dated 08/12/2024 at 3:28 PM, revealed Resident #1 refused to allow staff to assist with personal care and hygiene. Resident #1 did not perform those tasks for self or allow staff to assist. Resident #1 would not allow staff to touch, turn, clean, or reposition resident. 4.A review of a Progress Note, dated 08/13/2024 at 7:44 PM, revealed Resident #1 continued to refuse all activities of daily living care. 5.A review of a Progress Note, dated 08/14/2024 at 6:03 PM, revealed Resident #1 had eaten less than 25% or refused meals for 48 hours. 6.A review of a Progress Note, dated 08/15/2024 at 00:47 AM, revealed Resident #1 complained of feeling sore, but was not able to elaborate. Resident #1 continued to refuse care from the Certified Nursing Assistants (CNA). 7.A review of a Progress Note, dated 08/15/2024 at 00:57 AM, revealed Resident #1 refused pain medication for soreness. 8.A review of a Progress Note, dated 08/16/2024 at 10:02 AM, revealed Resident #1 was educated by a nurse on possible outcomes of not allowing nursing staff to give wound care including sepsis and death. Resident #1 stated, It can't be that bad. Resident #1 refused care from charge nurse, CNAs, wound care, and the doctor. 9.A review of a Progress Note, dated 08/17/2024 at 2:59 AM, revealed Resident #1 refused perineal care or any activity requiring movement in the bed. 10.A review of a Progress Note, dated 08/17/2024 at 3:48 AM, revealed Resident #1 was again educated on the importance of good hygiene related to bacteria and yeast infections. 11.A review of a Progress Note, dated 08/17/2024 at 2:37 PM, revealed Resident #1's room smelled as if the resident had a bowel movement but would not allow staff to change them. 12.A review of a Progress Note, dated 08/17/2024 at 10:23 PM, revealed Resident #1's room was odorous, and the resident had obvious need for care, but refused personal care. 13. Review of a Progress Note, dated 08/18/2024 at 12:40 PM, the provider stated, Resident #1 refused wound care from the Wound Care Nurse Practitioner (NP) from 05/15/2024 through 08/16/2024. Resident #1 was stated to have a stage IV open wound to the coccyx upon arrival to the facility, the wound was not assessed and had no dressing applied. Resident #1 had not allowed nursing staff to fully view the back, coccyx, or sacrum at any point since admission to the facility to assess how many wounds existed. Resident #1 is incontinent, and feces was likely in the wound. Resident #1 was informed of the infection risk and possible rehospitalization . Resident #1 was offered a visit with the mental health NP, but stated there was nothing wrong with them mentally. Resident #1 stated their favorite CNA was out with covid and the resident would not turn until they returned. 14.A review of a Progress Note, dated 08/18/2024 at 5:55 PM, revealed Resident #1 had a bowel movement but would not allow staff to clean the resident and there was a pungent smell emanating to the hallway. 15. A review of a Progress Note, dated 08/19/2024 at 00:37 AM, revealed staff noted maggots imbedded in Resident #1's flesh. Resident #1 initially refused the nurse's attempt at assessment, but did agree to the resident ' s leg being lifted a few inches. A maggot was noted on Resident #1's skin. Resident #1 stated, no desire to go to the hospital or do a telehealth visit with the on-call provider. Resident #1 stated, I am not in immediate danger. 16.A review of a Progress Note, dated 08/19/2024 at 9:19 AM, revealed the SSD informed Resident #1 continued refusal of care meant the doctor could fire them as a patient resulting in the facility issuing a letter of discharge because no one would be over seeing Resident #1's care. Resident #1 called the doctor a Little [expletive] and stated they never liked doctors anyway. Resident #1 refused to sign any paperwork for the facility and stated only one CNA could place a sheet under them. Resident #1 would not name whom the specific CNA was. 17.A review of a Progress Note, dated 08/19/2024 at 12:53 PM, revealed Resident #1 did not want to move onto a bariatric bed and stated to the SSD, I guess you'll have to find me another place to live then. 18.A review of a Progress Note, dated 08/19/2024 at 3:32 PM, revealed Resident #1 was aware of the wound situation with the maggots. 19.A review of a Progress Note, dated 08/19/2024 at 3:48 PM, revealed Resident #1 made excuses and pushed out every care intervention. 20.A review of a Progress Note, dated 08/19/2024 at 5:24 PM, revealed Resident #1 was coughing and had a grey skin color, covid test, lab work and a chest x-ray was ordered and refused. 21.A review of a Progress Note, dated 08/20/2024 at 9:44 AM, revealed Resident #1 had eaten less than 25% of meals or refused them for 48 hours. 22.A review of a Progress Note, dated 08/20/2024 at 10:38 AM, revealed Resident #1 was denied a transfer to a human development center because the resident did not have autism, down syndrome, or any intellectual disabilities and had a urinary catheter present. 23.A review of a Progress Note, dated 08/20/2024 at 11:51 AM, revealed Resident #1 had a Care Plan meeting in their room. The resident was asked about their food intake and stated, I'd rather just not eat, refused staff to use a mechanical lift to get them out of bed related to pain but refused pain meds, refused a wound care discussion which they did not think they needed stating they would not die from wounds. Resident #1 would not answer why they were on medication for their mood, stating I have never been depressed, nor am I depressed. Resident #1 wanted multiple medications stopped. Resident #1 was reapproached about wound care and stated, It would be best for you to leave. I really like you, so let's just end it here. 24.A review of a Progress Note, dated 08/20/2024 at 3:41 PM, revealed Resident #1 became agitated when the nurse asked the resident about how they were feeling and the issues they were having. 25.A review of a Progress Note, dated 08/21/2024 at 9:47 AM, revealed the SSD updated the ombudsman indicating the resident was aware of the maggots but still refused any care. The resident did not believe maggots were going to kill him. Resident #1 refused hospice services. The SSD expressed concern for the maggots and their danger to other residents. 26.A review of a Progress Note, dated 08/21/2024 at 2:21 PM, revealed Resident #1 was placed on isolation related to the maggots. Nursing staff explained the reason for the isolation to the resident and Resident #1 refused any care. Resident #1 stated, No you can just come in to give me my medicine, but everyone else can stay out. 27.A review of a Progress Note, dated 08/22/2024 at 00:18 AM, revealed a nurse asked Resident #1 to allow for pre-medication for pain followed by wound care in one hour. Resident #1 stated they would think about it. 28.A review of a Progress Note, dated 08/22/2024 at 7:40 AM, revealed Resident #1 had eaten less than 25% of meals or refused them for 48 hours. 29.A review of a Progress Note, dated 08/22/2024 at 10:30 AM, revealed Resident #1 was evaluated by a provider for Behavioral symptoms (e.g. agitation, psychosis): Other change in condition, Talks/Communicates Less, Change in skin color or condition. Outcomes of physical assessment were: Mental Status Evaluation: Altered Mental Status; Behavioral Status Evaluation: Other behavioral symptoms; Respiratory Status Evaluation: cough; Skin status Evaluation: wound. Recommendation from the provider was to Send to ER [emergency room ] for eval and treat. 30.A review of a Progress Note, dated 08/22/2024 at 10:41 AM, revealed Resident #1 refused wound assessment from Advanced Practice Registered Nurse (APRN) #11. Former-Assistant Director of Nursing (F-ADON) informed Resident #1 the need for wound care, new wounds on the legs, maggots seen near hips and now around legs, and failure to accept care could result in death. Resident #1 was informed of APRN #11's plan to send the resident to the ER for evaluation and treatment of change in skin color, unknown condition of the backside, maggots in the bed, and increased drowsiness. Emergency Medical Services (EMS) entered Resident #1's room and attempted to transfer resident to the ER at 10:25 AM. Resident #1 stated get out now. EMS left the building at 10:37 AM. 31.A review of a Progress Note, dated 08/22/2024 at 11:00 AM, revealed during the EMS incident the Former-Director of Nursing (F-DON) informed Resident #1 of the risk of sepsis, worsening of wounds, increase of fly larvae, and possibility death would occur. Resident #1 initially would not allow EMS team to speak, instead saying no, goodbye when they walked in the room and anytime, they began to speak. EMS asked questions to verify Resident #1 was alert and oriented which Resident #1 answered correctly, and EMS left. Resident #1 stated they were tired of people coming into room and bothering them. Resident #1 stated, it feels like I have a boot on my neck because you won't leave me alone. 32.A review of a Progress Note, dated 08/22/2024 at 11:49 AM, revealed a nurse contacted Adult Protective Services (APS). An APS Supervisor was made aware of Resident #1's decline and attempt to transfer them to the ER. APS stated Resident #1 had the right to refuse care even up to death. It was stated to APS, Resident #1 was not making sound decisions, and APS replied, a caseworker would be sent out to have a conversation with the resident and identify options moving forward. 33.A review of a Progress Note, dated 08/22/2024 at 1:09 PM, revealed Resident #1 refused to sign a Refusal of Care form and stated, for Christ's sake. 34.A review of a Progress Note, dated 08/22/2024 at 1:38 PM, revealed an APRN assessed Resident #1, and was found to be more lethargic, likely from risk of sepsis if not already, and would have to be transferred to the hospital if decline continued. Resident #1 stated, We will have to wait for me to get worse then. I don't want to go now. 35.A review of a Progress Note, dated 08/22/2024 at 4:30 PM, revealed attempts to reach out to Resident #1's friend and contact person were unsuccessful. 36.A review of a Progress Note, dated 08/23/2024 at 12:10 PM, revealed Resident #1 refused to acknowledge the Treatment Registered Nurse (Tx RN) or the floor nurse when they entered Resident #1's room, and refused to make eye contact. Resident #1 became angry when told wound care needed to be completed. Resident #1 stated, No you will not touch me and You need to leave. Resident #1 yelled, There is the door and leave now. The F-DON and F-ADON were notified. 37.A review of a Progress Note, dated 08/23/2024 at 3:15 PM, revealed Resident #1 refused to speak to the floor nurse when asked, How are you doing. 38. Review of a Progress Note, dated 08/23/2024 at 6:32 PM, revealed Resident #1's Primary Care Provider instructed the floor nurse to present hospice as an alternative since Resident #1 refuses care. Resident #1 stated. I do not want hospice. 39. A review of a Progress Note, dated 08/23/2024 at 7:00 PM, revealed Resident #1 had eaten less than 25% of meals or refused them for 48 hours. Resident #1 denied hunger and refused any supplements. During an interview on 12/02/2024 at 12:57PM, the Social Services Director (SSD) stated something was off (the SSD used hands, bilateral, with index fingers pointing toward head in circular motion) Resident #1 verbalized one thing appropriately but the actions were different, it didn't mesh up. The SSD stated there was no depression or appearance of depression, the resident was seen by the Psychiatric Mental Health Nurse Practitioner (PMHNP) via telehealth. The SSD stated the PMHNP does not come into the building to see residents in person. During an interview on 12/11/2024 at 10:14 AM, SSD stated, they did not identify any verbal behavior in the MDS form because they did not consider the term [expletive] to be cursing for the terms of the criteria, and Resident #1 never threatened anyone. Regarding Resident #1's behavior with bodily waste, dressing, and living environment the SSD stated no other behaviors were identified because the behaviors were the resident's baseline, and they only identified new behaviors. The surveyor questioned suicidal thoughts that were not new behaviors. The SSD stated, suicide is different, it is extreme. The SSD stated yes, Resident #1 was an extreme case. The SSD stated, I think I did all I could with [Resident #1] at the time. I was not considering it as other behaviors, but in hindsight, I would have answered yes to the question, which would have triggered the other assessment questions to be answered. The SSD stated, the unassessed areas of risk for significant illness/injury, significant interference in care, significantly intrude on the activity of others, were all present at the time of the 08/23/2024, assessment. The SSD stated the facility's Regional Ombudsman was an unbiased third party who advocated for the resident. The Regional Ombudsman was contacted regarding Resident #1's situation and the State Ombudsman was also involved; both the state Ombudsman and the Regional Ombudsman agreed, Resident #1 had the right to refuse care. They worked for the state Area Agency on Aging, it was located on the poster in the hall, it has a state seal on it. During a concurrent interview and observation on 12/11/2024 at 10:40 AM, the SSD accompanied the surveyor to the bulletin board where a poster for the Regional Ombudsman was posted. The SSD stated there was no state seal and no indication the ombudsman was part of the Department of Human Services (DHS) or, was with the Area Agency on Aging.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure sufficient staffing to meet residents' needs as evidenced by not following the facility assessment staffing guidelines for 74 of 87 shifts reviewed from 11/10/2024 day shift through 12/07/2024 night shift. The findings include: Facilities are required to conduct and document facility-wide assessment annually and as needed with substantial changes to determine what resources are necessary to care for its residents on a day-to-day basis. These may include resident census, disease types, services required by licensed personnel, equipment, resident's physical limitations and required assistance, residents with cognitive or intellectual impairments, and staff required to meet the needs of the residents. A review of a facility policy titled, Facility Assessment, dated 10/01/2024, indicated, the facility had an average daily census of 90. Common diagnoses of the facility's residents were: 1.Psychiatric/Mood/Substance use disorders- hallucinations, delusions, impaired cognition, mental disorder, depression, bipolar disorder (mania/depression), Schizophrenia (disorganized thinking and behavior usually with auditory hallucinations), Post-Traumatic Stress Disorder (PTSD), anxiety disorder, and behaviors that need interventions. 2.Heart/Circulatory System-congestive heart failure, coronary artery disease (blockages of the heart vessels), angina (chest pain), dysrhythmias (irregular heart rhythm), hypertension, orthostatic hypotension (blood pressure dropping with position changes), peripheral vascular disease, risk for bleeding and clots (deep vein thrombosis, pulmonary thrombo-embolism). 3.Neurological System- Parkinson's disease (neurodegenerative disease of the central nervous system), all or partial paralysis affecting either one side of the body left-right of from bottom to top (waist down or neck down), Multiple Sclerosis (autoimmune disease resulting in nerve damage to the brain and spinal cord), Alzheimer's disease, dementia, seizure disorders, stroke, traumatic brain injuries, Aphasia (language disorder affecting ability to communicate). 4.Intellectual Disabilities- Down Syndrome, Autism, and fetal alcohol syndrome. Vision issues- vision loss, cataracts, glaucoma, macular degeneration. Hearing issues-hearing loss. 5.Musculoskeletal System- fractures and arthritis. 6.Neoplasm- prostate cancer, breast cancer, lung cancer, colon cancer. Metabolic Disorders- diabetes, thyroid disorders, obesity, and morbid obesity. 7.Respiratory System- Chronic Obstructive Pulmonary Disease (COPD), Pneumonia, Asthma, and respiratory failure. 8.Genitourinary System- Renal insufficiency (impaired kidney function), neurogenic bladder (bladder control issues due to nerve problems), renal (kidney) failure, end stage renal (kidney) disease, urinary incontinence. 9.Blood Diseases- anemia and leukemia. Integumentary System- skin ulcers and injuries. Infectious Diseases- Skin and soft tissue infections, respiratory infections, tuberculosis, urinary tract infections, infections with multi drug resistant organisms, septicemia (infection in the blood stream), hepatitis (inflammation of the liver), influenza (the flu), and clostridium difficile (bacterial infection of the colon). The facility assessed acuity affecting licensed nurses were 36 residents on an altered diet or a swallowing disorder, 25 residents on oxygen, 3 residents with behavioral needs, 28 residents with injections, 3 residents requiring dialysis care on hemodialysis, 5 residents with indwelling catheters, 2 residents requiring intermittent catheterization, 12 residents on hospice, 7 residents with wound care, 3 residents on tube feedings. The facility assessed acuity affecting nurse aides revealed 33 residents were dependent upon staff for dressing, 41 for bathing, 36 for transfers, 15 for eating, 36 for toileting, 35 for oral hygiene, 40 for mobility, 34 for upper body dressing and 48 for lower body dressing. The facility assessed their coverage needs to adequately meet the residents' daily needs per shift as: Day Shift: 1 Registered Nurse (RN), 5 Licensed Practical Nurses (LPNs), 15 Certified Nurse Assistants (CNAs), 2 Med Techs, 2 Nurse Aides (NAs), and 1 other Evening Shift: 0 RNs, 4 LPNs, 10 CNAs, 1 Med Tech, 2 NAs, 0 other Night Shift: 1 RN, 3 LPNs, 8 CNAs, 0 Med Techs, 0 NAs, 0 other A review of the facility's Resident Matrix printed 11/25/2024 revealed, 50 out of 97 facility residents had a fall, 13 of those with a major injury, 45 had a diagnosis of Alzheimer's/Dementia, 12 were on transmission based precautions (isolation requiring personal protective equipment), 12 were on hospice care, 10 were being treated for an infection, 6 had a pressure injury, 6 had a urinary catheter in place, 3 required tube feedings, and 1 required IV (intravenous) therapy. A review of the documents Detailed Hours, for November and December daily staffing was reviewed from the employee's time clock punch reports starting with the day shift on 11/10/2024 through the end of the night shift on 12/07/2024. 83 occurrences a Certified Nurse Assistant (CNA) worked more than 13 consecutive hours, 35 occurrences a Licensed Practical Nurse (LPN) worked more than 13 consecutive hours, 11 occurrences a Register Nurse (RN) worked more than 13 consecutive hours, 9 occurrences a Nurse Assistant (NA), and 3 occurrences a Med Tech (Medication Assistant- Certified [MA-C]). 10 occurrences an LPN employed in a non-bedside role was asked to work as a bedside nurse. Using staffing guidelines defined by the facility in their 10/01/2024 Facility Assessment the bedside staff coverage was found lacking coverage by either a partial or complete open shift on: 11/10/2024 Day Shift-1 RN, 3 LPNs, 2 CNAs, 1 MA-C Evening Shift- 2 MA-C 11/11/2024 Evening Shift-1 LPN 11/12/2024 Day Shift-1 LPN Evening Shift-1 LPN, 1 NA, 1 MA-C Night Shift-1 RN, 1 CNA 11/13/2024 Evening Shift-1 LPN, 1 CNAs, 1 MA-C, 1 NA Night Shift-1 LPN 11/14/2024 Days Shift-1 LPN, 1 NA Evening Shift-1 LPN, 3 CNAs, 1 MA-C, 1 NA Night Shift-1 LPN, 2 CNAs, 1 MA-C, 2 NA 11/15/2024 Days Shift-1 LPN, 1MA-C Evening Shift-2 LPNs, 1 CNA, 1 MA-C Night Shift-2 CNAs 11/16/2024 Day Shift-2 LPNs, 1 MA-C, 1 NA Evening Shift-1 LPN, 1 MA-C, 1 NA Night Shift-2 CNAs 11/17/2024 Day Shift-1 LPN, 5 CNAs, 1 MA-C, 2 NAs Evening Shift-2 LPNs, 1 CNA, 1 MA-C, 2 NAs Night Shift-1 LPN, 3 CNAs 11/18/2024 Day Shift-1 CNA, 1 NA Evening Shift-1 LPN, 2 CNAs, 1 MA-C Night Shift-1 RN 11/19/2024 Evening Shift-2 NA 11/20/2024 Evening Shift-1 LPN, 1 CNA, 2 NAs, 1 MA-C 11/21/2024 Day Shift-1 NA Evening Shift-1 CNA, 1 MA-C Night Shift-1 LPN 11/22/2024 Day Shift- 1 NA Evening Shift-2 LPNs, 1 CNA, 1 MA-C Night Shift-1 LPN, 3 CNAs 11/23/2024 Day Shift-1 CNA, 1 MA-C, 1NA Evening Shift-1 CNA, 1 MA-C, 2 NAs Night Shift-3 CNAs 11/24/2024 Day Shift-1 NA Evening Shift-1 LPN, 2 CNAs, 1 MA-C, 1 NA Night Shift-1 LPN 11/25/224 Day Shift-1 RN Evening Shift-1 LPN, 2 NAs Night Shift-1 RN 11/26/2024 Evening Shift-1 LPN Night Shift-1 RN, 2 CNAs 11/27/2024 Evening Shift-1 LPN, 1 MA-C, 1 NA Night Shift-1 CNA 11/28/2024 Day Shift-3 LPNs Evening Shift-1 LPN, 1 MA-C, 1 NA Night Shift-1 LPN, 1 CNA 11/29/2024 Days Shift-1 LPN, 1 CNA, 1 MA-C, 1 NA Evening Shift-1 LPN, 4 CNAs, 1 MA-C, 2 NA Night Shift-1 LPN, 4 CNAs 11/30/2024 Day Shit-2 LPNs, 3 CNAs, 1 MA-C, 2 NAs Evening Shift-1 MA-C, 2 NAs Night Shift-3 CNAs 12/01/2024 Day Shift-1 RN, 2 LPNs, 6 CNAs, 1 MA-C, 1 NA Evening Shift-1 CNA, 1 NA Night Shift-1 LPN, 1 CNA 12/02/2024 Day Shift-1 RN Evening Shift-1 LPN, 2 CNAs, 1 MA-C, 2 NAs Night Shift-1 RN 12/03/2024 Day Shift-1 NA Evening Shift-1 LPN, 2 CNAs, 1 MA-C, 1 CNA Night Shift-1 RN, 1 CNA 12/04/2024 Day Shift-1 LPN Evening Shift-1 LPN, 2 CNAs, 1 MA-C, 1 NA Night Shift-1 LPN 12/05/2024 Day Shift-1 LPN, 1 MA-C, 1 NA Evening Shift-1 LPN, 1 MA-C, 1 NA Night Shift-1 LPN 12/06/2024 Day Shift-1 RN, 1 NA Evening Shift-2 LPNs, 1 CNA,1 MA-C, 1 NA Night Shift-1 LPN, 2 CNAs 12/07/2024 Day Shift-1 RN, 1 LPN, 5 CNAs, 2 NA, 2 MA-C Evening Shift-1 MA-C, 1 NA A review of a document titled Incident by Incident Type, reviewed for a date range from 11/10/2024 to 11/25/2024, incidents classified as; 3 episodes of physical aggression, 1 in self-inflicted injury, 3 witness falls, 11 unwitnessed falls, 2 bumped/struck incident, 2 other incidents. A review of a document titled Incident by Incident Type, December fall list to current date of 12/07/2024, revealed another 7 falls, 3 witnessed and 4 unwitnessed. During an interview on 12/03/2024 at 6:40 AM, RN #17 stated, she had never been asked to take 3 halls and would not because it was too demanding. RN #17 stated the facility had a lot of staff turnover especially CNAs, and she heard the MDS (Minimum Data Sheet) nurse had quit. During an interview on 12/07/2024 at 10:40 AM, CNA #30 stated, she had been on the unit alone with one LPN when she arrived. CNA #30 stated she had asked the DON twice to obtain assistance. We have 8 showers today and we only have 2 done. There are 6-8 showers scheduled every day. CNA #30 stated the DON was aware of the short staffing and staffing was always short. When state is in the building, we show more staff because the consultants and administrative staff help too. During a concurrent observation and interview on 11/27/2024 at 08:05 AM, Resident #15 was sitting in the secure unit dining room being assisted by staff to eat breakfast. Resident #15 was unable to answer questions. LPN #18 stated Resident #15 received a scheduled opioid pain medication and resident was unable to communicate due to disease progression. Needs are anticipated and pain assessed by facial grimacing. Review of the Incidents by Incident Type, from 08/11/2024 to 11/25/2024, revealed Resident #15 had an unwitnessed fall on 08/31/2024 at 3:55 PM. A review of Incidents by Incident Type, dated 12/01/2024 to 12/07/2024, revealed Resident #15 had an unwitnessed fall on 12/04/2024 at 9:35 AM. A review of Progress Note, dated 12/03/2024 at 12:20 PM, revealed Resident #15 hit head on door frame of room and had a purple bruise to forehead. A review of Progress Note, dated 12/04/2024 at 12:11 PM, Incident & Accident description revealed resident walked into door fame on 12/03/2024 witnessed by aide. New helmet ordered. A review of Resident 15 ' s Admission Record, indicated the facility admitted Resident #15 with diagnoses that included dementia, osteoarthritis, and anxiety disorder. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/2024, revealed Resident #15 had a Staff Interview for Mental Status (SAMS) score of 3 which indicated the resident was severely impaired for daily decision making. Resident #15 required setup/cleanup assistance with eating and was dependent upon staff for oral hygiene, toileting, shower/bathing, dressing, and personal hygiene; required substantial assistance transferring to the toilet, and partial to moderate assistance with bed mobility, sitting to standing, laying to sitting on side of the bed, from sitting to standing, and transferring from chair to bed and bed to chair. Resident required a wheelchair for ambulation and was dependent upon staff for mobility. Resident #15 ' s active diagnoses included: arthritis, dementia, anxiety disorder, repeated falls, pain, and vitamin D deficiency. Resident #15 had 2 falls since admission with no injury; was receiving an antianxiety, antidepressant, and opioid medications. Resident #15 was receiving speech, occupational, and physical therapies. Care areas triggered included cognitive loss/dementia, visual function, communication, urinary incontinence, falls, and psychotropic drug use. A review of Resident #15's Care Plan, revised on 10/24/2024, revealed Resident #15 required a secured/special care unit related to dementia to provide a secure safe environment; had actual falls, 1 fall with fracture; had limited physical mobility related to severe cognitive impairment; had behavioral indicators/history of behaviors removing non-skid socks, safety helmet and C-collar; was elopement risk/wandering related to severe cognitive impairment and poor safety awareness; had delirium; had hypertension; had dehydration or potential for dehydration; had anxiety disorder; had psychotropic medications; had alteration of musculoskeletal status, fracture of C1 vertebra; had chronic pain related to a long term condition causing widespread body pain and tiredness; had actual impaired vision related to cataract. Interventions included staff educated to redirect if going into other resident rooms, proper fitting non-skid socks, move to high visual area, provide fidget blanket, ensure wearing proper footwear/non-skid socks, fall mat while in bed, therapy referral, encourage resident to remain in high observation area due to poor safety awareness, non-skid strips placed in front of recliner, redirect to high traffic/visible area, siderails for bed mobility, required supervision by 1 staff to walk independently, encourage participation in activity programs, encourage resident to wear helmet and keep on both non-skid socks, staff to be vigilant and encourage resident to keep on helmet, set routine of wake and sleep times, anticipate needs, assess for fall risk, distract from wandering, offer pleasant diversions, identify pattern of wandering and intervene as appropriate, administer medications as ordered, review medications for side effects, monitor and report onset signs and symptoms, changes in behavior, monitor vital signs; keep call light in reach, needs safe environment with even floors, free of spills, adequate light, bed in low position at night, remove blanket from resident when ambulating, lock wheelchair, behavioral consults as needed, monitor and report adverse reactions of medications including unsteady gait, frequent falls, anticipate and meet needs, keep cervical collar in place may be removed for showers, no sudden turning of head, keep midline while showering, give opioid pain medication and monitor for side effects, clean and maintain glasses daily and as needed. A review of Order Summary, revealed Resident #15 had an order, dated 09/20/2024, to reside on the secure unit related to dementia and behavioral disturbance; 09/05/2024, J-collar to be worn at all times related to a displaced posterior fracture of the first cervical vertebra; 12/04/2024 monitor hematoma to head for signs and symptoms [of] adverse change; 07/10/2022 antihypertensive; 09/16/2024 opioid medication as needed (PRN); 02/13/2024 antidepressant; 01/11/2024 opioid at bedtime for pain; and 09/04/2024 antianxiety. A review of Medication Administration Record (MAR), revealed Resident #15 received medications on 12/04/2024, that included: an antihistamine, an antihypertensive, an antidepressant, an antianxiety, an opioid, and a cervical collar, PRN opioid medication for pain. Review of (Contract Medical Provider Company) Advance Registered Practice Nurse (APRN) visit notes on 08/31/2024 at 4:02 PM, for Resident #15, revealed a medically necessary visit related to a change in condition for an unwitnessed fall, bleeding from face and confused baseline. Review of Symptoms (ROS) indicated resident was chronically ill, anxious, not oriented to time, place, or person, appeared uncomfortable, and had a significant amount of bleeding from the nose/mouth. Order given to send resident to emergency room (ER). Review of the [Hospital] History and Physical, dated 08/31/2024, revealed Resident #15 was transferred from [Hospital] emergency room for neurological evaluation, after a fall in a long-term care facility, identified a C1 fracture after a computed tomography (CT) scan (radiological test providing a cross section of structures inside the body). Additional diagnoses included vascular dementia, attention deficit disorder, and psychiatric disorder. Resident #15 unable to provide history due to vascular dementia. Assessment revealed cervical spine fracture. Review of the [Hospital] Record, emergency physician note dated 08/31/2024, revealed Resident #15 had an unwitnessed fall, acute fractures of anterior and posterior arch C1 and nasal bone. Physical exam revealed, dry blood in nares, upper lip laceration with sutures in place; neurologic [exam]: speech is rapid and unclear, moves all extremities; psychiatric[exam]: anxious and agitated. Review of the [Hospital] Discharge Summary, dated 09/04/2024, revealed Resident #15 ' s advanced dementia status, was verbal and unable to hold normal conversation, and at best oriented to self, was now failure to thrive and high risk for readmission and clinical deterioration, remained full code, cervical collar in place. Review of (Contract Medical Provider Company) Advance Registered Practice Nurse (APRN) visit notes on 09/06/2024 at 4:02 PM, for Resident #15, revealed a medically necessary visit related to recurrent falls and admitted to facility after hospital stay from 08/31/2024 to 09/06/2024. Resident #15 was found to have a cervical fracture at C1 and nasal bone fracture. ROS revealed, not oriented to time, place, or person with recent memory and remote memory abnormal. Opioid medication refilled for osteoarthritis. Orders included physical therapy, occupational therapy and speech therapy. During a concurrent observation and interview on 12/07/2024 at 10:38 AM, Resident #22 lying in bed, cervical collar noted to neck. CNA #30 stated the resident had a fall and had a neck fracture at C2. CNA #30 was not aware of when the fall occurred. Review of Incidents by Incident Type, dated 12/01/2024 to 12/07/2024, revealed Resident #22 had a witnessed fall on 12/03/2024. Review of Witnessed Fall #5931 revealed CNA #31 was assisting Resident #22 back to room, in wheelchair, and resident fell , striking forehead causing 4 cm laceration. Resident sent to ER per physician order. Review of the (Hospital) Emergency Department (ED), visit dated 12/03/2024, revealed Resident #22 arrived via ambulance related to fall from wheelchair with 2 cm laceration to forehead and skin tear to right hand. Reported somehow fell forward out of wheelchair earlier in the day striking forehead. Diagnoses revealed an acute (closed fracture of cervical spine odontoid (C2 [second bone/vertebra in the neck]) and 2 cm x 4 cm laceration to forehead. Review of Progress Note Nsg I&A DON Follow Up, dated 12/09/2024, revealed Resident #22 had a 6 cm x 4 cm laceration, after falling out of wheelchair in hallway, hit forehead, physician notified, and order received to send to ER. A review of the Admission Record, indicated the facility admitted Resident #22 with diagnoses that included late onset senile dementia, anxiety disorder, restlessness and agitation, and right hip pain. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/24/2024, revealed Resident #22 had a Staff Interview for Mental Status (SAMS) score of 3 which indicated the resident was severely impaired for daily decision making. Resident #22 exhibited physical and verbal behavior symptoms, required partial/moderate assistance with eating and oral hygiene, required substantial/maximal assistance with toileting, shower/bathing, dressing, putting on/taking off footwear and personal hygiene. Required substantial/maximal assistance with bed mobility, position changes, and transfers; utilized a wheelchair for mobility with supervision to moderate assistance. Active diagnoses included senile dementia, anxiety disorder, right hip pain, and no pain during the assessment period. Falls included 2 without injury. Medications included antianxiety, antidepressant and opioid. A review of Resident #22's Care Plan revised on 10/23/2024, revealed Resident #22 had an activity of daily living (ADL) self-care performance deficit related to dementia and impaired balance and required assistance of 2 staff to move between surfaces. Resident #22had limited physical mobility and required a wheelchair with assistance of 1 staff for locomotion. A goal to remain free of complications related to immobility and fall related injury was initiated on 12/04/2024; Resident #22 had an actual fall on 12/03/2024. Interventions initiated on 12/04/2024 included: leaning forward and resting arms on thighs while sitting in wheelchair, providing supportive assistance with mobility as needed, specialized chair to provide comfort and support due to poor trunk control. A review of Order Summary, revealed Resident #22 had an order to admit to the secured unit, comfort care, send to ER for laceration to forehead on 12/03/2024, antianxiety medication, anticonvulsant, opioid concentrate, and an antidepressant. During an interview on 12/08/2024 at 11:00 AM, LPN #1 stated, during report, received information that Resident #22 fractured their neck when they face planted out of the wheelchair on to the floor during transportation by staff. During an interview on 12/11/2024 at 09:50 AM, the Administrator stated there were falls involving Resident #15 and Resident #22, with major injuries. One fall, Resident #22 was witnessed during care, and Resident #15, unwitnessed, was found sitting on the floor with one sock on, and one off and we considered it a slip and fall. No investigation and no report to the State Agency was done on falls as they were not considered injuries of unknown origin. During an observation on 12/07/2024 at 10:40 AM, Resident #24 lying in bed supine with knees bent, feet flat on mattress, bruising (purple/blue) noted to lateral left knee, left eye, temporal area, cheekbone to jaw (deep purple, green, yellow). CNA #30 stated resident had a lot of falls and tried to keep resident comfortable. CNA #30 did not know when bruises or last fall occurred. Review of Progress Note, dated 11/30/2024 at 6:30 AM, revealed Resident #24 was on the floor with knees bent, inside secure unit, back to door, one small lump and one large lump on left side of forehead assisted resident into wheelchair. APRN #11 notified. Review of Progress Note, dated 11/30/2024 at 2:16 PM, revealed Resident #24 was on the floor of TV room on buttocks scooting self, nonskid socks in place, brief wet, care provided, hospice notified. Review of Incidents by Incident Type, dated 12/01/2024 to 12/07/2024, revealed no fall information for Resident #24. Review of the Admission Record, indicated the facility admitted Resident #24 with diagnoses that included: Insufficient blood flow to the brain, a progressive disease that destroys memory and other mental functions, and major depressive disorder. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/17/2024, revealed Resident #24 had a Staff Interview for Mental Status (SAMS) score of 3 which indicated the resident was severely impaired for daily decision making. Resident #24 required setup/cleanup assistance with eating; supervision/touch assistance with oral hygiene; substantial/maximal assistance with toileting, shower/bathing, dressing, putting on/taking off footwear, and personal hygiene; was independent with bed mobility and transfer from lying to sitting, sitting to standing and bed to chair and chair to bed transfers; supervision or touch assistance with toilet transfer and was independent with ambulation and did not require the use of assistive devices. Active diagnoses included depression, decreased blood flow to the brain, and a progressive disease that destroys memory and other mental functions. Health conditions included two falls without injury and two falls with injury. Medications included antipsychotic, antianxiety, antidepressant and opioid, and was currently on hospice care. Review of Resident #24's Care Plan revised on 10/21/2024, revealed Resident #24 had behavioral indicators that included hitting and moving furniture; communication problem; potential for skin tear; actual falls; and cognitive impairment. Interventions included: anticipation of needs, administer and monitor medications, distraction including validation, talk about family and boys, beauty shop; anticipate and meet needs; identify causative factors and eliminate when possible; nonskid socks, toileting every 2 hours while awake, continue to monitor injury related to sitting or crawling on floor, ensure recliner foot rest is down when unoccupied, be in high observation areas for safety, review medications, non-skid strips to floor by bed; and use visual cues, positive approach techniques, engage in conversation. Review of Order Summary, revealed Resident #24 had active orders for hospice services, secure unit, skin tear treatment to left hand and elbow, opioid for pain, and antianxiety medications. During an observation on 12/07/2024 at 11:40 AM, Resident #26 was lying in bed, rubbing their left thigh area, requesting pain medication and (Name Brand) topical pain gel for left leg. Resident #26 stated they had not received medication today. A review of the Admission Record, indicated the facility admitted Resident #26 with diagnoses that included polyneuropathy (condition affecting peripheral nerves causing pain, burning and numbness in the arms and legs), depression, hypothyroidism, chronic lymphocytic leukemia (cancer of the blood and bone marrow with symptoms of swollen lymph nodes, bruising, and pain) not in remission, hypertension, and pain. A review of Medication Administration Record, revealed Resident #26 had medications ordered at 8:00 AM that included, an oral hormone replacement tablet, an external pain patch to left thigh, 2 different oral antihypertensive tablets, an oral opioid for pain and the pain assessment level was documented as 0, an antianxiety tablet, two capsules for neuropathy. All 8:00 AM medications indicated they were provided to Resident #26. No PRN (as needed) medications were documented as administered. Blood pressure monitoring done during the 7a-7p shift indicated a reading of 152/60. Readings from 12/1/2024 to 12/6/2024 during the 7a - 7p shift were 143/76, 120/77, 132/72, 124/62, 126/78, and 118/68 respectively. Administration of the second dose of anxiety, neuropathy, and topical pain medications were changed. A review of the Medication Administration Audit Report, dated 12/11/2024 at 1:35 PM, for all medication, 7A-7P shift, revealed Resident #26 received the hormone replacement medication at 10:21 AM, one antihypertensive medication was given at 10:23 AM, and the opioid pain medication was given at 10:25 AM, the antianxiety tablet was given at 10:21 AM, capsules for neuropathy were given at 10:21 AM, the external pain gel was applied at 10:27 AM, one antihypertensive medication was given at 10:27 AM, and the pain patch was applied at 10:32 AM. Second dose of the opioid pain medication was given at 6:29 PM, the antianxiety tablet was given at 1:26 PM, the neuropathy medication was given at 1:26 PM, and external pain gel was applied at 1:32 PM and not adjusted based upon the actual administration time of the first dose. A review of the controlled drug sign-out book, page 109, revealed Resident #26 ' s controlled opioid pain medication was signed out on 12/07/2024 at 10:00 AM by Social Services Discharge Nurse (SSDN). During an interview on 12/07/2024 at 11:51 AM, the SSDN stated Resident #26 had received pain medication that included the opioid and 2-acetaminophen as well as the topical pain gel, earlier. The SSDN stated she was the On Call this weekend and did not start medication until 8:00 AM due to the number of call-ins, trying to find coverage for the shift, and getting report from night shift. The SSDN stated she had to cover as the floor nurse for a 12-hour shift Saturday and Sunday due to the weekend nurse that worked the shift was no longer working at the facility. The SSDN stated she was responsible for residents on the right side of 500 hall from room [ROOM NUMBER] all the way down hall to the end and back up the left side of the hall to room [ROOM NUMBER], and all residents on 600 hall. The SSDN stated there were 2 CNAs currently on 400 hall, 500 hall, and 600 hall. However, upon arrival for the shift, SSDN stated there were 2 CNAs on 400, 1 CNA on 500, 1 CNA on 6 hall, and 2 nurses for 400, 500 and 600 halls. SSDN stated there were usually 2 nurses and they split 500 hall, and the nurses were trying to help with residents due to only 1 CNA on 500 and 1 CNA on 600 hall. The Director of Nursing (DON) was working to find more help, and CNAs were moved around to have enough for 400, 500, and 600 halls. During an interview on 12/11/2024 at 12:12 PM, the DON stated it had been a hectic day, someone was sent out to the hospital. We are dealing with humans and some people need more time. The nurse needed to call the doctor, needed reeducation on time management, and needed to ask for help. Resident #26 should have received the antihypertensive and opioid pain medication on time because the consequences of giving a twice daily blood pressure medication late, could cause blood pressure medications to be given too close together it could bottom them out (cause blood pressure to drop too low) and late pain medications could cause the resident to be in pain longer than they should be. During an observation on 12/07/2024 at 11:35 AM, Resident #27 stated they had not received their morning medications and was asking for a nurse. LPN #14 overheard Resident #27 from the hallway and stepped into Resident #27's room and stated she would return shortly with medications. A review of the Admission Record indicated the facility admitted Resident #27 with diagnoses that included hypothyroidism, major depressive disorder, anxiety, and pain. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/21/2024, revealed Resident #27 had a BIMS score of 15 which indicated the resident was cognitively intact. Resident #27 required substantial to maximum assistance with oral hygiene, bathing, personal hygiene, and dressing; required setup/cleanup assistance with eating; required substantial to maximum assistance with wheelchair mobility. Active diagnoses included hypertension, anxiety, depression, and pain occasionally interfering with sleep and day to day activities. Current medications included antianxiety, antidepressant, and opioid. A review of an Order Summary, revealed Resident #27 was to receive a daily antidepressant, an opioid pain medication twice daily, a thyroid hormone replacement daily, an antihypertensive twice daily, and an antianxiety medication twice daily. A review of the Medication Administration Record, revealed Resident #27 had medications ordered at 8:00 AM that included, oral antidepressant capsules, an oral opioid pain medication and the pain assessment level was documented as 0, an oral thyroid replacement tablet, an oral antihypertensive tablet, and an oral antianxiety tablet. All 8:00 AM medications indicated they were provided to Resident #27. No PRN medications were documented as administered. A review of the Medication Administration Audit Report, dated 12/09/2024 at 4:50 PM, for all administration, all shift, all documented, revealed Resident #27 received the antidepressant at 12:29 PM, the opioid pain medication at 12:31 PM, the thyroid hormone replacement at 12:29 PM, the antihypertensive at 12:27 PM and the antianxiety medication at 12:29 PM. Time of administration of the second doses of twice daily medications were not adjusted. During an interview on 12/07/2024 at 11:22 AM, Licensed Practical Nurse (LPN) #14 stated they were responsible for all residents on 400 hall and 4 rooms on 500 hall. LPN #14 [TRUNCATED]

Based on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to maintain an account of all controlled substances for 1 (Medication Cart 300-Hall) of 5 medication carts reviewed for accounting of controlled substances; and maintain a record of controlled substances for 4 Residents on 2 medication carts (Resident #20, Resident #21, Resident #22, and Resident #23) of 5 medication carts reviewed for accurate records; and it was determined that the facility failed to ensure resident medications were administered within the specified time to ensure continued therapeutic status was maintained for 3 (Resident #26, # 27 and #28) of 3 residents who stated medications were not received. Findings include: A review of a facility policy and procedure titled, Medications Oral, revised on 11/22/2016, indicated use of equipment and supplies that included the medication administration record (MAR), a medication cup and medication. The procedure indicated use of the equipment and supplies and identification of resident, explanation of procedure, positioning of resident to take medication, providing and encouraging water intake with medication, remaining with resident during medication administration, documenting information in the medical record and reporting unusual or abnormal findings to charge nurse. A review of the medication package insert for [brand name] (calcium channel blocker), with a revised date of 06/2014, described the indication for usage was to lower blood pressure as part of lowering cardiovascular risk. Concentrations in blood reach plateau in 6 hours of dose and fluctuate over the 24-hour dosing interval. Administration was according to the patient's needs. A review of the medication package insert for [brand name] tablets (a thyroid hormone replacement), with a revised date of 08/2005, described the indication for usage was to supplement or replace thyroid hormone due to hypothyroidism. The general principal goal of replacement therapy included achievement and maintenance of a normal state by individualized dosing. A review of the medication package insert for [brand name] (an opioid agonist), with a revised date of 03/2008, described the indication for usage was treatment of moderate to moderately severe pain. Concentration in blood reaches peak in two hours with a steady state (consistent concentration) in two days. Patient notification included understanding of the dose limit and time interval between doses due to depression of the respiratory system, seizures and death. A review of the medication package insert for [brand name] (an antianxiety agent), with a revised date of 11/2010, described the indication for usage was to treat anxiety. Patient information included taking the medication consistently to assure safe and effective use. A review of the medication package insert for [brand name] (an anticonvulsant), with a revised date of 04/2009, described it was used for neuralgia (pain caused by damaged nerves) and should be taken as prescribed. A review of the medication package insert for [brand name] (a benzodiazepine), with a revised date of 03/2021, described indications for use that included: anxiety disorder, and should be taken exactly as your healthcare provider tells you to take it. A review of the medication package insert for [brand name]topical gel (dermatological NSAID), with a date of 07/2009, described indication for use of pain relief in joints such as knees and hands. Instructions that included: using medication exactly as prescribed, at the lowest dose and for the shortest amount of time. A review of the medication package insert for [brand name] (an ACE inhibitor), with a revised date of 12/2014, described the indication for use was treatment for hypertension and should be adjusted according to blood pressure response. A review of the medication package insert for [brand name] (an antidepressant), with a revised date of 12/04/2008, described the indications for use included: major depressive disorder, anxiety disorder, peripheral neuropathic pain, fibromyalgia, and chronic musculoskeletal pain. Therapy should be continued as directed. A review of the medication package insert for hydrocodone bitartrate and acetaminophen, with a date of 2009, described indications for use as severe pain management, using the lowest effective dosage based on patient treatment goals. The medication guide instructs to take exactly as prescribed. A review of the medication package insert for [brand name] (a beta-blocker), with a revised date of 11/10, described indications for use included: hypertension and dose should be individualized. At the end of a 12-hour dosing interval, blood pressure could rise. A review of the medication package insert for [brand name] (medication used to treat dementia related to Alzheimer ' s disease), with a revised date of 12/2018, described the indication for use was a form of dementia, and taken once daily as prescribed. If a dose was missed, take the next dose at the usual time. A review of the medication package insert for [brand name] (a Beta Blocker), with a revised date of 2/2008, described the indications for use included: hypertension. Information for patients included: taking regularly and continuously and if a dose was missed should only take the next scheduled dose. A review of the medication package insert for [brand name] (an oral NMDA blocker), with a revised date of 11/2018, described the indication for usage was moderate to severe dementia, and if dose was missed, should take the next scheduled dose. A review of the Admission Record, indicated the facility admitted Resident #26 with diagnoses that included: polyneuropathy (condition affecting peripheral nerves causing pain, burning and numbness in the arms and legs), depression, hypothyroidism, chronic lymphocytic leukemia (cancer of the blood and bone marrow with symptoms of swollen lymph nodes, bruising, and pain) not in remission, hypertension, and pain. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/13/2024, indicated Resident #26 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. Resident #26 required setup/cleanup assistance with eating, oral hygiene, and personal hygiene; was independent toileting and bed mobility, required supervision or touch assistance with dressing and walking. Active diagnoses included: polyneuropathy, depression, hypothyroidism, cancer, hypertension, and experienced frequent pain that occasionally effected sleep, therapy activities, day to day activities, and required pain medication. Current medications included an opioid. A review of the Care Plan, revised on 08/27/2023, indicated Resident #26 had an Activity of Daily Living (ADL) self-care performance deficit related to impaired mobility and polyneuropathy; had pain medication therapy; exhibited behavioral indicators related to depression that included rudeness, sarcastic remarks, rejection of care, abusive language; had hypertension and would maintain a blood pressure within the normal parameters, remain free of signs and symptoms and complications; had hypothyroidism. Interventions included: providing assistance and administering medications as ordered by the physician. A review of an Order Summary, indicated Resident #26 had blood pressures monitored twice daily, an antihypertensive medication daily, a synthetic compound used to treat neurological condition three times daily, antianxiety medication three times daily, opioid pain medication twice daily, thyroid hormone replacement daily, topically patch for pain applied daily to left thigh, and a topical pain gel applied to knees three times a day. A review of the December Medication Administration Record (MAR), indicated Resident #26 had medications ordered on 12/07/2024 at 8:00 AM that included, an oral hormone replacement tablet, an external pain patch to left thigh, 2 different oral antihypertensive tablets, an oral opioid for pain and the pain assessment level was documented as 0, an antianxiety tablet, two capsules for neuropathy. All 8:00 AM medications indicated they were provided to Resident #26. No PRN (as needed) medications were documented as administered. Blood pressure monitoring done during the 7a-7p shift indicated a reading of 152/60. Readings from 12/1/2024 to 12/6 2024 during the 7a - 7p shift were 143/76, 120/77, 132/72, 124/62, 126/78, and 118/68 respectively. Administration of the second dose of anxiety, neuropathy, and topical pain medications were changed. A review of the Medication Administration Audit Report, dated 12/11/2024 at 1:35 PM, for the administration date of 12/07/2024, included all medication, 7A-7P shift, indicated Resident #26 received the hormone replacement medication at 10:21 AM, one antihypertensive medication was given at 10:23 AM, and the opioid pain medication was given at 10:25 AM, the antianxiety tablet was given at 10:21 AM, capsules for neuropathy were given at 10:21 AM, the external pain gel was applied at 10:27 AM, one antihypertensive medication was given at 10:27 AM, and the pain patch was applied at 10:32 AM. Second doses of the opioid pain medication was given at 6:29 PM, the antianxiety tablet was given at 1:26 PM, the neuropathy medication was given at 1:26 PM, and external pain gel was applied at 1:32 PM and not adjusted based upon the actual administration time of the first dose. A review of the controlled drug sign out book, page 109, indicated Resident #26 controlled opioid pain medication was signed out on 12/07/2024 at 10:00 AM by Social Services Discharge Nurse (SSDN). During an observation on 12/07/2024 at 11:40 AM, Resident #26 was lying in bed, rubbing their left thigh area, requesting pain medication and (Name Brand) topical pain gel for left leg. Resident #26 stated they had not received medication today. During an interview on 12/07/2024 at 11:51 AM, SSDN stated Resident #26 had received pain medication that included the opioid and 2-acetaminophen as well as the topical pain gel, earlier. The SSDN stated she was the On Call this weekend and did not start medication pass until 8:00 AM due to the number of call ins, trying to find coverage for the shift and getting report from night shift. The SSDN stated she had to cover as the floor nurse for a 12-hour shift Saturday and Sunday due to the weekend nurse that worked the shift was no longer working at the facility. The SSDN stated she was responsible for residents on the right side of 500 hall from room [ROOM NUMBER], all the way down hall to the end and back up the left side of the hall to room [ROOM NUMBER], and all residents on 600 hall. The SSDN stated there were 2 CNAs currently on 400 hall, 500 hall, and 600 hall. However, upon arrival for the shift, the SSDN stated there were 2 CNAs on 400, 1 CNA on 500, 1 CNA on 6 hall, and 2 nurses for 400, 500 and 600 halls. The SSDN stated there were usually 2 nurses and they split 500 hall, and the nurses were trying to help with residents due to only 1 CNA on 500 and 1 CNA on 600 hall. The Director of Nursing (DON) was working to find more help, and CNAs were moved around to have enough for 400, 500, and 600 halls. During an interview on 12/11/2024 at 12:12 PM, the DON stated it had been a hectic day, someone was sent out to the hospital. We are dealing with humans and some people need more time. The nurse needed to call the doctor, needed re-education on time management, and needed to ask for help. Resident #26 should have received the antihypertensive and opioid pain medication on time because the consequences of giving a twice daily blood pressure medication late could cause blood pressure medications to be given too close together and it could bottom them out (cause blood pressure to drop too low) and late pain medications could cause the resident to be in pain longer than they should be. A review of the Admission Record indicated the facility admitted Resident #27 with diagnoses that included hypothyroidism, major depressive disorder, anxiety, and pain. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/21/2024, indicated Resident #27 had a BIMS score of 15 which indicated the resident was cognitively intact. Resident #27 required substantial to maximum assistance with oral hygiene, bathing, personal hygiene, and dressing; required setup/cleanup assistance with eating; required substantial to maximum assistance with wheelchair mobility. Active diagnoses included: hypertension, anxiety, depression, and pain occasionally interfering with sleep and day to day activities. Current medications included: antianxiety, antidepressant, and opioid. A review of an Order Summary, indicated Resident #27 was to receive a daily antidepressant, an opioid pain medication twice daily, a thyroid hormone replacement daily, an antihypertensive twice daily, and an antianxiety medication twice daily. A review of the December MAR indicated Resident #27 had medications ordered on 12/07/2024 at 8:00 AM, that included oral antidepressant capsules, an oral opioid pain medication and the pain assessment level was documented as 0, an oral thyroid replacement tablet, an oral antihypertensive tablet, and an oral antianxiety tablet. All 8:00 AM, medications indicated they were provided to Resident #27. No PRN medications were documented as administered. A review of the Medication Administration Audit Report, dated 12/09/2024 at 4:50 PM, for the administration date of 12/07/2024 included all administration, all shift, all documented, indicated Resident #27 received the antidepressant at 12:29 PM, the opioid pain medication at 12:31 PM, the thyroid hormone replacement at 12:29 PM, the antihypertensive at 12:27 PM and the antianxiety medication at 12:29 PM. Time of administration of the second doses of twice daily medications were not adjusted. During an interview on 12/07/2024 at 11:22 AM, Licensed Practical Nurse (LPN) #14 stated they were responsible for all residents on 400 hall and 4 rooms on 500 hall. LPN #14 has worked for facility 6 months and their normal schedule was 7a-7p Friday, Saturday, and Sunday. LPN #14 has been assigned to work on 400 and 500 halls for one month and usually has 2-3 CNAs with 1 CNA float for 400 and 500 halls. During an observation on 12/07/2024 at 11:35 AM, Resident #27 stated they had not received their morning medications and was asking for a nurse. LPN #14 overheard Resident #27 from the hallway, stepped into Resident #27's room, and stated she would return shortly with medications. During an interview on 12/11/2024 at 12:12 PM, the DON stated Resident #27 not receiving the antihypertensive, opioid pain medication, and antianxiety medication on time was not an effective way to give medications. The DON stated he contacted the provider and was told it was okay to give the medication. The DON stated if it had been him, he would not have been that far behind. A review of the Admission Record, indicated the facility admitted Resident #28 with diagnoses that included: depression, anxiety, hypertension, and neuralgia (pain caused by nerve irritation or damage). The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/15/2024, indicated Resident #28 had a BIMS score of 10 which indicated resident had moderate cognitive impairment. Resident #28 required setup/cleanup assistance with eating, oral hygiene, and personal hygiene; required partial to moderate assistance with toileting, showering and dressing of lower body; and required supervision/touch assistance with wheelchair mobility. Resident #28 active diagnoses included: hypertension, anxiety, and depression. A pain assessment was not completed. Resident #28 was receiving opioid pain medication. A review of Resident #28 ' s Care Plan, revised on 11/14/2024, indicated Resident #28 had a history of behaviors with interventions that included: anticipating and providing needs before resident becomes overly stressed; had impaired cognitive function/dementia as evidenced by the BIMS score; had hypertension; had depression; received a psychotropic medication for anxiety; had pain medication therapy; had a mood problem and depression; and had chronic pain. Interventions included: administering and monitoring the effectiveness of medications as ordered, keep routine consistent to decrease confusion, and report changes in usual routine. A review of Order Summary, indicated Resident #28 was to receive an acetylcholinesterase inhibitor (interferes with the breakdown of an enzyme in the body decreasing anxiety) tablet one time a day for anxiety, a synthetic compound used to treat neurological condition two times daily, an antihypertensive two times daily, and a dementia medication daily. A review of the December MAR indicated Resident #28 had medications ordered at 8:00 AM that included, an oral acetylcholinesterase inhibitor tablet for anxiety daily, an oral dementia tablet daily, a pain assessment each shift, an antihypertensive tablet two times daily, and a capsule for neuralgia two times daily. No PRN medications were documented as administered. A review of the Medication Administration Audit Report, dated 12/09/2024 at 4:49 PM, for the administration date of 12/07/2024, included all administration, all shifts, all documentation indicated Resident #28 received the acetylcholinesterase inhibitor tablet for anxiety at 10:46 AM, the oral dementia tablet at 10:47 AM, the antihypertensive tablet at 10:47 AM, and the capsule for neuralgia at 10:46 AM. Time of administration of the second doses of twice daily medications were not adjusted. During an observation on 12/07/2024 at 11:33 AM, Resident #28 asked LPN #14 for morning medications. LPN #14 responded, we are running behind and I will let your nurse know. During an interview on 12/11/2024 at 12:12 PM, the DON stated the nurse for Resident #28 should have called the provider and notified them the resident's antihypertensive medication was late and received instructions. Review of Progress Notes dated 11/09/2024 to 12/12/2024, had no entry for provider notification regarding late medications for Resident #26, Resident #27, or Resident #28. During an interview on 12/07/2024 at 11:39 AM, LPN #14 stated the residents should have received medications between 7 and 9. It was a rough morning with call ins. CNA staff was short and we could not get anyone to come in, so the nurses had to cover for the CNAs, putting us behind. LPN #14 stated residents should receive medications on time and the Director of Nursing (DON) was aware of medication being late and staffing. During an interview on 12/11/2024 at 12:12 PM, the Director of Nursing (DON) stated medication administration times were 1 hour before and after the scheduled times in Point Click Care (PCC). If a nurse was outside the 1-hour window, they should call the provider and ask for instructions. In a case with a twice a day medication, the doctor may need to consider whether to give it or not. The nurse would want to pass it on in report. During an interview on 12/11/2024 at 1:37 PM, the SSDN and surveyor reviewed the controlled drug sign out book, page 109. SSDN stated Resident #26 received the opioid pain medication at 10:00 AM, I thought it was sooner. The SSDN stated the on-call provider was notified regarding giving medications late, however, did not recall the name of the provider. SSDN was unable to locate the progress note with the provider notification in the electronic health record, filtered the progress notes to include medication administration notes and was still unable to locate a provider notification for Resident #26, Resident #27, or Resident #28, and stated the note may be on a paper somewhere on the desk that has not been entered yet. The SSDN stated it was important to receive medications when ordered, especially blood pressure and other things to keep medication levels consistent and notification should be documented. On 12/11/2024 at 2:38 PM, surveyor was at the front door exiting the facility and the SSDN stopped surveyor and stated the note regarding provider notification was found right where I said it was and was now in the electronic health record. A review of a facility policy titled, Medication Storage in the Facility, revised January 2018, indicated, Medications are stored safely and securely accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication room, carts, and medication supplies are locked when not attended by persons with authorized access. A review of the facility's undated policy titled Abuse, Neglect, Misappropriation and Exploitation Investigating and Reporting indicated, abuse was patterns or deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. A review of an in-service, conducted by Former- Assistant Director of Nursing (F-ADON) on 11/21/2024, indicated, during narcotic counts nursing staff was to look at the medication cards and verify all pills are accounted for. A review of an Incident and Accident Report submitted on 11/21/2024 at 11:17 AM, to the OLTC indicated, during administration of Resident #16's antianxiety medication current Assistant Director of Nursing (ADON) identified a missing pill from the (Name Brand) antianxiety medication card on the 300-Hall cart. On 11/25/2024, findings indicated, current ADON did not catch the missing pill during morning shift narcotic count, the missing pill was not located in the narcotic box by F-ADON, it was believed the card was damaged on the back side due to the tight fit of the large volume of cards in the narcotic box, nurses were in-serviced on visualizing the medication cards to verify the count and the Abuse and Neglect policy with emphasis on misappropriation of property, and a new narcotic box was ordered for additional storage. No drug diversion activities were identified. A review of an Incident and Accident Report submitted on 11/21/2024 at 12:39 PM, to the Office of Long-Term Care (OLTC) by F-ADON indicated, during a full match back completed by the F-ADON and Nurse Consultant #14 on the 300-Hall narcotic box to verify the count due to previously missing narcotics Resident #15 (Name Brand) pill card was missing one pill. On 11/25/2024, findings indicated, current ADON did not catch the missing pill during morning shift narcotic count, the missing pill was not located in the narcotic box by F-ADON or Nurse Consultant #14, it was believed the card was damaged on the top right corner due to the tight fit of the large volume of cards in the narcotic box, nurses were in-serviced on visualizing the medication cards to verify the count and the Abuse and Neglect policy with emphasis on misappropriation of property, and a new narcotic box was ordered for additional storage. No drug diversion activities were identified. A review of an in-service conducted by F-ADON on 11/22/2024 indicated, nursing staff was provided education on properly reading measurements on a morphine bottle. A review of an Incident and Accident Report submitted on 11/22/2024 at 12:43 PM, to the OLTC indicated, during the change of shift narcotic count on 11/22/2024 at 7:23 AM, for the 300-Hall Medication cart Resident #16's (Name Brand) bottle contained 2 milliliters (ML) less liquid medication than expected. The (Name Brand) was immediately surrendered for destruction and a replacement bottle was obtained. On 11/27/2024, findings indicated, no spillage or waste had been reported, an assessment of the nurse's administration knowledge and skills were preformed, and an in-service was conducted to re-educated on how to properly identify the increment marks on the side of the (Name Brand) bottle. No drug diversion activities were identified. During a concurrent interview and observation on 11/26/2024 at 5:44 PM, a controlled medication count was completed on the 200-Hall medication cart. Resident #23's (Name Brand) controlled narcotic pain medication had 43 pills in the medication card, the controlled medication book, page 34, reported the (Name Brand) controlled narcotic pain medication count was 44. Licensed Practical Nurse (LPN) #15 stated, they forgot to sign out the morning dose. A review of Resident #23's November Medication Administration Record (MAR) revealed, on 11/26/2024, LPN #15 administered (Name Brand) controlled narcotic pain medication to Resident #23 at 8:54 AM, eight hours and fifty minutes prior to the narcotic count. During a concurrent interview and observation on 11/26/2024 at 5:54 PM, a controlled medication count was completed on the 200-Hall medication cart. Resident #21's (Name Brand) controlled nerve pain medication had 24 pills in the medication card, the controlled medication book, page 37, reported the (Name Brand) controlled nerve pain medication count was 25. LPN #15 stated, they forgot to sign out the morning dose. A review of Resident #21's November MAR revealed, Resident #21's (Name Brand) controlled nerve pain medication was scheduled at 8:00 AM and signed out by LPN #15. During a concurrent interview and observation on 11/26/2024 at 6:23 PM, a controlled medication count was completed on 300-Hall medication cart. Resident #20's (Name Brand) controlled narcotic pain medication had 19 pills in the medication card, the controlled medication book, page 99, reported the (Name Brand) controlled narcotic pain medication count was 20. LPN #18 stated, they forgot to sign out the morning dose. A review of Resident #20's November MAR revealed, Resident #20's (Name Brand) controlled narcotic pain medication was scheduled of 8:00 AM, and not signed out by LPN #18. It was signed out by LPN #1. 50924

Based on observations, interviews and record reviews it was determined that the facility failed to keep medications safely secured for 1 medication cart of 1 medication cart reviewed for medication storage. A review of a facility policy titled, Medication Storage in the Facility, revised January 2018, indicated, Medications are stored safely and securely accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication room, carts, and medication supplies are locked when not attended by persons with authorized access. During a concurrent observation and interview on 11/28/2024 at 6:13 AM, Registered Nurse (RN) #12 was seen passing medication at the end of 600-Hall. The medication cart was parked in the hallway outside suite 610. RN #12 took medication into room [ROOM NUMBER]-B. The medication cart was unlocked, Resident #9 ' s medication card was left sitting on top of the cart, and the computer screen was left open. RN #12 returned to the cart at 6:17 AM. RN #12 stated, they should lock the cart because someone could come by and take something. Regarding Resident #9's antifungal medication card sitting on top of the cart RN #12 stated, it's just (brand name). RN #12 stated things like that might matter in other places, but not around here. A review of Resident #9's medication card revealed, a one-time dose of (Name Brand) antifungal 150 milligram (MG) tablet was in an un-popped bubble of the medication cart left sitting unattended on top of the 600-Hall medication cart. During an interview on 11/28/2024 at 6:40 AM, the Administrator was made aware of the potentially dangerous situation by the surveyor. The Nurse Consultant stated they were going to have a talk with RN #12 and immediately exited the room. 50924

Based on observations, interviews, and facility policy review, it was determined that the facility failed to ensure hand hygiene was performed during meal service for 1 dining room of 4 dining rooms observed during meal service. This failed practice had the potential to affect all residents receiving meals in the 100-hall dining room. Findings include: A review of a facility policy titled, Hand Hygiene, dated 11/22/2017, indicated the primary means of preventing infections was hand hygiene and handwashing/hand hygiene procedures were to be followed by all personnel to prevent spread of infections to residents and others. During an observation on 11/29/2024 at 5:39 PM, Nursing Assistant (NA) #9 removed a meal tray from the insulated cart and served a meal to a resident, removed items from the tray and placed on table, removed lids. NA #9 repeated this process, serving 7 residents in the 100-hall dining room. NA #9 did not perform hand hygiene prior to removing the first tray or between meal trays, during the observation. During an observation on 11/29/2024 at 5:39 PM, Certified Nursing Assistant (CNA) #10 removed a meal tray from the insulated cart and served a meal to a male resident in the 100-hall dining room. CNA #10 removed items from the tray, placed them on the dining table and removed lids. CNA #10 returned to the insulated cart and removed a second tray, returned to the same table, removed items from the tray and placed them on the dining table, in front of a second male resident. CNA #10 removed lids, and opened an 8 oz carton of milk, by folding back the sides at the peak of the top and placed a fingernail of their index finger in the seam and pulled out, inserted the index finger further into the opening and pulled, fully opening the spout. No straw was provided to the resident. No hand hygiene was performed by CNA #10 prior to removing the meal tray from the cart, in between serving the two male residents' meals, and was not wearing gloves while opening the milk carton. During an interview on 11/29/2024 at 5:44 PM, NA #9 stated hands should be sanitized between serving resident trays to keep from spreading germs to the residents and making them sick. During an interview on 11/29/2024 at 5:47 PM, the Administrator stated hands should be sanitized in between serving trays and the aides know it so they do not spread infection. During an interview on 11/29/2024 at 5:49 PM, CNA #10 stated hands should have been sanitized between serving meal trays and should not have placed a finger into the opening of the milk carton where a resident places their mouth to drink, because it spreads infection. 49688

Based on observation and interview, the facility failed to ensure expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen. These failed practices had the potential to affect 92 residents who received meals from the kitchen. The findings are: During an observation of the dry goods storage area on [DATE] at 11:14 AM, 3 plastic gallon jugs of red vinegar with a use by date of [DATE] were located on a bottom shelf. On [DATE] at 11:18 AM, ten individual serving containers of cocktail sauce with a use by date of [DATE] were located on the second metal shelving unit, inside a box containing mustard and ketchup packets. On [DATE] at 11:52 AM, a sealed plastic bag containing an open package of Italian seasoning with a use by date of [DATE] was located on the second metal shelving unit. On [DATE] at 11:55 AM, fourteen bags of corn chips with a use by date of [DATE] were located on the top self of the third shelving unit. The Surveyor asked the Dietary Manager (DM) if expired items should be in the storage room. The DM stated expired items should not be in the storage room and should be disposed of, so the residents are not served the items. The DM removed the expired items from the storage room. In an observation on [DATE] at 4:52 PM, dates of foods stored in the walk-in refrigerator and freezer revealed the following: a. 6 fried chicken patties with frost visible on the patties, in an unsealed plastic storage bag labeled with a use by date of [DATE]; the Dietary Manager stated these are no good. b. 10 Pork fritters in a plastic storage bag labeled with a use by date of [DATE], the bag was also torn. c. 7 fried chicken patties in a plastic storage bag labeled with a use by date of [DATE]. d. Solid mass of uncooked boneless chicken thighs, in a plastic storage bag labeled with a use by date of [DATE]. The Dietary Manager stated the outdated items should not be in the freezer to be served to the residents.

Based on record review, observations, and interviews, the facility failed to ensure staff did not stand over residents while assisting with meal service to maintain and promote dignity for 1 (Resident #26) of 1 sampled resident. The findings are: A review of the Residents Rights, not dated, and part of the Admission Packet, indicated, This facility will promote and protect the rights of every individual resident. Each resident in this facility has the right to receive treatment without discrimination as to race, color, religion, sex, national origin, age, disability, or source of payment. Each resident has the right to be treated with consideration, respect and full recognition of dignity and individuality. A review of an Admission Record indicated the facility admitted Resident #26 with a diagnosis that included dementia. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/15/2024, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated the resident had severe cognitive impairment. Resident required setup or clean-up assistance for eating. A review of Resident #26's Physician Orders, revealed an order, dated 12/07/2022, to admit to long term care secured unit related to dementia and elopement risk. A review of Resident #26's Care Plan, revised 02/17/2023, revealed the resident had an activity of daily living (ADL) self-care performance deficit related to dementia; with an intervention that included requiring limited assistance of one staff for eating; revised on 02/17/2023. On 06/10/2024 at 12:38 PM, Resident #26 was observed at the dining table on the secure unit during meal service. Certified Nursing Assistant (CNA) / Unit Manager stood to the right side of Resident #26 and gave Resident # 26 a bite of mechanical chicken with gravy. On 06/10/2024 at 12:42 PM, CNA / Unit Manager stood to the right side of Resident #26 and gave Resident #26 a drink of water. On 06/10/2024 at 12:48 PM, CNA / Unit Manager stood to the right side of Resident #26 and gave Resident #26 a bite of ice cream. CNA / Unit Manager then sat down and started assisting Resident #9. On 06/11/2024 at 3:31 PM, CNA / Unit Manager revealed during an interview that a resident's dignity was maintained while assisting residents during meal service, by encouraging the residents on what they can do, sit down next to them, use clothing protectors, and keep their hands and face clean, because they deserve to have that respect. On 06/12/2024 at 3:21 PM, the Assistant Director of Nursing (ADON) / Infection Control Preventionist (ICP) revealed during an interview that staff should sit at the eye level of the residents while assisting with meal service, so the resident doesn't feel inferior, and that it was a dignity issue. On 06/12/2024 at 3:54 PM, the Director of Nursing (DON) revealed during an interview that staff should sit eye level with the residents during meal service so the residents don't feel inferior. The DON was asked what the expectations were for staff regarding following the facilities policy and procedures and guidelines. The DON stated, They've got to follow them 100%, that's just the way it is.

Based on observation, record review, and interview the facility failed to ensure privacy was maintained for 2 (Resident #46, and #392) sampled residents due to personal health information left unattended in public areas. The findings are: 1. On 06/11/2024 at 10:00 AM, the Administrator provided a document titled Resident Rights documenting, .The Right to Privacy and Confidentiality, including the right to: .To know they are assured private and confidential treatment of all information contained in their medical records, including photographs, and that their consent, or the consent of their legal representative, is required for the release of information to persons not otherwise authorized to receive it . 2. Review of the Medical Diagnosis portion of Resident #46's electronic health record revealed diagnoses of cerebral edema, chronic kidney disease, and dementia. a. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/18/2024 indicated a Brief Interview for Mental Status (BIMS) score of 07 (0-7 suggest severe cognitive impairment) for Resident #46. b. On 06/12/2024 at 5:29 AM, the Surveyor walked down 600 Hall and observed an unattended medication cart resting against the wall with Resident #46's Medication Administration Record (MAR) pulled up and medications visible to passersby. c. On 06/12/2024 at 05:35 AM, Registered Nurse (RN) #6 approached and the Surveyor asked RN #6 if it was standard practice to leave the computer screen open and visible to people in the hallway. RN #6 told the Surveyor that yes, most the time he leaves the screen up, it will close itself off. When asked if there was any reason that RN would not want to expose resident information the Surveyor was told there was no reason not to leave it up, unless you don't want someone else to see what you are getting. 3. Review of the Medical Diagnosis portion of Resident #392's electronic health record revealed diagnoses of collapsed vertebra, spinal stenosis, and atrial fibrillation. a. The Admission MDS with an ARD of 05/26/2024 indicate a BIMS score of 15 (13-15 suggest cognitively intact) for Resident #392. b. On 06/12/2024 at 05:57 AM, the Surveyor walked down 600 Hall and observed an unattended medication cart with the screen open. Resident #392's picture was in view, and Hydrocodone was pulled up on the screen. RN #6 was observed coming out of room [ROOM NUMBER]. The Surveyor spoke with RN #6 and the nurse reiterated that the computer screen will turn itself off, and there was no reason not to leave it up unless you do not want someone else to see what you are getting. 4. On 06/12/2024 at 11:48 AM, the Director of Nursing (DON) asked if leaving the computer screens open with resident information in public areas is standard practice. The DON confirmed that it is a Health Insurance Portability and Accountability Act (HIPAA) violation because anyone could read the residents personal information.

Based on observation, record review, and interview the facility failed to ensure necessary services were provided in a timely manner to maintain good hygiene for 1 (Resident #21) sampled resident that was unable to carry out personal care without assistance. The findings are: 1. Review of the Medical Diagnosis portion of Resident #21's electronic health record revealed diagnoses of depressive disorders, bipolar disorder, and rheumatoid arthritis. a. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/09/2024 indicated a Brief Interview for Mental Status (BIMS) score of 15 (13-15 suggest cognitively intact). Section H indicated Resident #21 was occasionally incontinent of urine. b. A Care Plan, revised 04/12/2021, indicated Resident #21 had an activity of daily living self-care performance deficit related to arthritis, and required supervision/ setup help of 1 staff for toilet use. c. A Care Plan, revised 04/24/2023, indicated Resident #21 had functional bladder incontinence and instructed staff to clean the perineal area with each incontinence episode. c. On 06/10/2024 at 11:50 AM, the Surveyor smelled a urine odor in Resident #21's room. d. On 06/10/2024 at 12:10 AM, Resident #21 told the Surveyor they had been incontinent of urine and stated, I used to help change my linens, but with my bad knee and since I had pneumonia, I just cannot do it. Resident #21 stood up and removed a folded blanket covering a large wet and brown ring on the sheet covering the middle right side of the bed. Resident #21 reported calling for assistance earlier in the morning, and when housekeeping came by Resident #21 was told residents Certified Nursing Assistance (CNA)s would have to change the wet sheets today. e. On 06/10/2024 at 2:04 PM, while observing Resident #21's room CNA #5 walked in with clean linens. The Surveyor asked CNA #5 to describe Resident #21's sheets. It looks like where something was spilled or had an accident. Resident #21 told CNA #5 that nothing was spilled. CNA #5 confirmed the brown spot would be caused by the accident drying and said staff should round every two hours. The Surveyor asked why staff are expected to round every 2 hours. CNA #5 said it can cause skin breakdown and infection. Resident #21 said they had a rash in their perineal area right now and has been putting cream on it. f. On 06/11/2024 at 11:01 AM, the Administrator provided a policy titled Perineal/Incontinence Care that did not apply. g. On 06/12/2024 at 11:52 AM, while interviewing the Director of Nursing (DON) the surveyor asked how often staff are expected to round on residents. The DON told the Surveyor that staff was expected to check on residents and provide personal care every two hours and confirmed that if a resident is wet the peri-care should not be put off because it can cause skin breakdown, and infection. h. On 06/13/2024 at 08:16 AM, the CNA Coordinator provided course documentation for all employees for Care Academy, showing CNA #5 checked off on incontinent care on 05/22/2024.

47916 Based on record review, observations, and interviews, the facility failed to ensure the residents environment was free from accidents and hazards to prevent possible ingestion and or injury for 2 (Resident #49 and #56) of 2 sampled residents; and failed to ensure chemicals and handheld razor blades were stored and contained properly; and failed to ensure a smoking assessment was obtained for 1 (Resident #295) of 1 sampled resident. The findings are: Review of the Resident Rights, no date, from the admission packet indicated, The facility will promote and protect the rights of every individual resident. In addition, each resident in this facility has the following rights: receive adequate and appropriate medical care, nursing care, protective and support services, and personal cleanliness in a safe and clean environment. A review of the Safety Data Sheet: Soothe & Cool Moisture Barrier Ointment, dated 05/30/2015, indicated, Causes eye irritation. May be harmful if swallowed. A review of the Safety Data Sheet: {brand name Germicidal Wipes}, dated February 18, 2019, revealed Avoid contact with eyes and skin. Avoid breathing vapors. Store locked up. Store in a well-ventilated place. 1. A review of an Admission Record indicated the facility admitted Resident #49 with diagnoses of muscle wasting and dementia. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/22/2024, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident was severely cognitively impaired. A review of Resident #49's Physician Orders, for the month of 06/2024, revealed an order, dated 03/20/2024, to admit to secured neighborhood related to exit seeking. There was not an order noted for moisture barrier ointment. On 06/10/2024 at 1:51 PM, Resident #49 was lying in bed. A full tube of barrier moisture barrier ointment was observed on the armoire in Resident #49's room. No staff were present. On 06/11/2024 at 9:26 AM, Resident #49 was in bed. A full tube of moisture barrier ointment was observed on the armoire in Resident #49's room. No staff were present. On 06/12/2024 at 5:08 AM, Resident #49 was in bed. A full tube of moisture barrier ointment was observed on the armoire and unattended. On 06/12/2024 at 10:35 AM, Certified Nursing Assistant (CNA) #10 revealed during an interview that barrier moisture cream should be stored in the wound care cart. On 06/12/2024 at 10:46 AM, Licensed Practical Nurse (LPN) #8 revealed during an interview barrier moisture cream should be locked up in the treatment/wound cart when not in use. On 06/12/2024 at 11:52 AM, the Director of Nursing (DON) revealed during an interview that barrier moisture cream should be in the wound care cart because we don't want them (the residents) to access it. 2. A review of an Admission Record indicated the facility admitted Resident #56 with a diagnosis of Alzheimer's disease. The Quarterly MDS with an ARD of 05/09/2024 revealed Resident #56 had a BIMS score of 00, which indicated the resident had severe cognitive impairment. On 06/10/2024 at 12:22 PM, a container of germicidal disposable wipes was observed on Resident #56's bathroom counter. On 06/10/2024 at 1:44 PM, a container of germicidal disposable wipes was observed on Resident #56's bathroom counter. On 06/11/2024 at 9:29 AM, Resident #56 was lying in bed. A container of germicidal disposable wipes was observed in the bathroom on the counter. On 06/12/2024 at 5:11 AM, Resident # 56 was lying in bed. A container of germicidal disposable wipes observed in the bathroom on the counter. On 06/12/2024 at 10:35 AM, CNA #10 revealed during an interview the {brand name} germicidal wipes should be stored in a locked storage or the nurse's station because the residents could eat them or get hurt, and that all staff was responsible for ensuring they were not left out in the resident's rooms. On 06/12/2024 at 10:46 AM, LPN #8 revealed during an interview the germicidal wipes should be locked in her cart because they are hazardous and that it was a team effort to ensure they were not left out in the resident's rooms. On 06/12/2024 at 11:52 AM, an interview with the DON revealed the germicidal wipes should be locked in the housekeeper's cart because they didn't want anyone to get a hold of them. On 06/10/2024 at 11:58 AM, the Surveyor observed a work cart sitting unattended on 400 Hall containing a hand held razor cutting blade, spray oil based lubricant, and disinfectant wipes. On 06/10/24 at 12:02 PM, [Contract] worker identified spray oil-based lubricant, disinfectant wipes, and a handheld razor cutting blade resting on the 400 Hall maintenance cart. [Contract] worker told the Surveyor that he had a very important call and walked away leaving cart unattended. On 06/10/2024 at 2:00 PM, the Surveyor spoke with the Administrator and identified the contract [NAME]. During the interview, it was discussed that the Administrator had asked the maintenance worker with contract worker to not leave the cart unattended due to the risk to residents. On 06/12/2024 at 11:50 AM, the DON was asked if it was standard practice to leave an unattended work cart with spray oil-based lubricant, disinfecting wipes, and a handheld razor cutting blade in a resident hallway. The DON told the Surveyor no, it is not standard because a resident could get any of these things and do damage to themselves or others. On 06/12/2024 at 02:04 PM, the Administrator reported the facility did not have any hazard policies. 3. A review of a document titled, Smoking Policy and Procedure, revealed .Upon admission, readmission, quarterly and with a significant change in condition, residents who smoke or use electronic cigarettes will be assessed for their ability to smoke safely using the Safety - Smoking Assessment form . A review of a Admission/ Medicare 5 day MDS revealed that Resident #295 had a BIMS score of 15, which indicates that cognition is intact. A review of a Care Plan dated 05/22/2024 documented Resident #295 is a smoker and is at risk for complications from smoking, including injury. Interventions included to provide Resident #295 with the following while smoking: observation, constant supervision, protective gear (smoking apron), Resident #295 has been oriented to smoking procedures and areas; and Resident #295 will be able to demonstrate the ability to verbalize understanding that smoking materials are for use only in designated smoking areas. On 06/12/2024 at 2:30 PM, the surveyor observed Resident #295 smoking outside with a staff member. Resident #295 lit the cigarette and extinguished the cigarette. Resident #295 had a smoking apron on. Review of Resident #295's electronic health record revealed no smoking assessment had been completed. 4. A review of Residents Rights indicated that residents will .Receive .a safe and clean environment . a. A review of Resident #33's Order Summary dated 06/12/2024 revealed the following medical diagnoses: enterocolitis, epilepsy, and epileptic syndromes with complex partial seizures. A review of Resident #33's Care Plan dated 04/30/2024 documented Resident #33 has impaired cognitive function/dementia or impaired thought processes as evidenced by BIMS score of 8/15. Intervention included that Resident is to be cued, re-oriented and supervised as needed. A review of Resident #33's 5-day Admission MDS with an ARD of 05/04/2024 revealed a BIMS score of 8, which indicates moderate cognitive impairment. b. A review of Resident #92's Order Summary dated 06/13/2024 revealed the following medical diagnoses: vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A review of Resident #92's Care Plan dated 05/13/2024 revealed the resident has impaired cognitive function/dementia or impaired thought processes as evidenced by BIMS score. A review of Resident #92's Admission MDS with an ARD of 05/19/2024 revealed that the resident had a BIMS score of 5, which indicates severe cognitive impairment. On 06/11/2024 at 10:27 AM, the Surveyor observed a can of aerosol anti-perspirant in Resident #92 and Resident #33's room sitting on a wardrobe counter. On 06/12/2024 at 10:20 AM, the Surveyor observed a can of aerosol anti-perspirant in Resident #92's and Resident #33's room sitting on a wardrobe counter. During an interview on 06/12/2024 at 10:20 AM, the surveyor asked CNA #7 if aerosol deodorant spray should be sitting out in a resident's room, and she stated no. The surveyor asked why these items should not be left out and CNA #7 stated because they could [NAME] it and hurt themselves. During an interview on 06/12/2024 at 11:16 AM, the surveyor asked LPN #8 should products be left out if they say keep out of reach of children. LPN #8 stated no. The surveyor asked LPN #8 why products of that nature should not be left out. LPN #8 responded because they are hazardous chemicals. Also, the surveyor asked if aerosol deodorant should be left in a room. LPN #8 responded no. During an interview on 6/12/24 at 12:10 PM, the surveyor asked Director of Nursing (DON) why products or items should not be left out that say keep out of reach of children such as aerosol deodorant. The DON stated it's dangerous it could harm someone. It could hurt someone such as the resident or family and we have children in here a lot. The DON stated products that state keep out of reach of children should not be left in rooms. The DON stated these items should be locked up in the nurses' cabinet off from the dining room. 49866

Based on observation, record review, and interview, the facility failed to ensure controlled narcotics were properly documented when acquired from the pharmacy to prevent the risk of misappropriation, and to ensure a record of receipt and disposition was in place for Ativan oral concentrate in 1 of 2 medication rooms. This failed practice had the potential to affect 5 sampled Residents (Residents #12, #56, #73, #79, and #342) of 21 residents with a physician's order for Ativan. The findings are: 1.a. On 06/11/2024 at 11:15 AM, the Surveyor asked Registered Nursing (RN) #1 to see documentation of the emergency kit medications from the narcotic box from the 100/200/300 Hall medication room, for the following medications: a. Ativan 2mg/ml (milligram/milliliter), 30ml unopened vial. b. Ativan oral concentrate 1mg/0.5 ml 5 syringes c. Ativan 2mg/ml injectable is out of stock. b. On 06/11/2024 at 11:21 AM, Registered Nurse (RN) #1 reviewed the narcotic book and told the surveyor there was no documentation for Ativan oral concentration in the narcotic book. The surveyor asked about the process for documenting controlled medications that arrive from the pharmacy. RN #1 said the nurse that accepted and signed for the delivery should have documented the medication in the controlled narcotic book. The surveyor asked if all controlled substances should be recorded in the narcotic book, and why would that be important. RN #1 said all controlled medications should be documented in the controlled narcotic book because legally as nurses we are responsible for those medications and their administration. The Surveyor asked for documentation from the pharmacy showing when Ativan oral concentrate was last received by the facility. c. On 06/11/2024 at 12:06 PM, the Director of Nursing (DON) provided documentation of pharmacy consolidated delivery forms showing Ativan 2.5 ml was received on 05/29/2024 at 11:00 PM. d. On 06/11/2024 at 3:56 PM, RN #1 provided documentation showing Ativan 2mg/ml oral syringes with 2.5ml availability was added to page 17 of the narcotic book. RN #1 confirmed the narcotic box contains 5-1mg/0.5ml syringes or Ativan oral concentrate. e. On 06/12/24 at 11:50 AM, the Director of Nursing (DON) was asked what procedures staff are expected to follow when a controlled medication is delivered to the facility. The DON expects nursing staff to count it with the driver, sign the manifest, and immediately document the medication in the logbook, because the medications could have disappeared, and nobody would have known it. g. On 06/12/2024 at 12:57 PM, the Administrator provided a policy titled Medication Storage in the Facility that did not address the documentation of the receipt, documentation and disposition of medications from the pharmacy.

Based on record review, observations, and interviews, the facility failed to ensure medications were stored in accordance with state laws and accepted standards of pharmacy practice for 3 (Resident #49, #72, and #342) of 3 sampled residents; and the facility failed to ensure a narcotic box was double locked to prevent the possible misappropriation, ingestion and or injury. The findings are: 1. A review of the Safety Data Sheet: Betadine Solution Swab sticks, dated April 13, 2015, indicated, This product is a topical microbicide. Not for oral use. Causes mild skin irritation. Avoid contact with skin, eyes, or clothing. A review of the Safety Data Sheet: [Name Brand] Ultra Powder Collagen Wound Dressing, dated 10/19/2022, indicated, Handling and Storage: Always wear recommended personal protective equipment. Avoid inhaling product. Avoid contact with eyes. A review of an Admission Record indicated the facility admitted Resident #49 with diagnoses of muscle wasting and dementia. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/22/2024, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident was severely cognitively impaired. A review of Resident #49's Physician Orders, for the month of 06/2024, revealed an order, dated 03/20/2024, to admit to secured neighborhood related to exit seeking. There is not an order for ultra powder collagen wound dressing or 10% Iodine swab sticks. On 06/10/2024 at 1:51 PM, Resident #49 was lying in bed. A package of ultra powder collagen wound dressing 1 gram was observed on the armoire in the resident's room unattended. An open package of Iodine 10% containing 3 swabs was observed on the armoire in Resident's room. On 06/11/2024 at 9:26 AM, Resident #49 in bed eyes closed. A package of ultra powder collagen wound dressing 1 gram was observed on the armoire in the Resident's room unattended. An open package of Iodine 10% containing 3 swabs was observed on the armoire in the Resident's room unattended. On 06/12/2024 5:08 AM, Resident # 49 observed in bed with eyes closed. A package of ultra powder collagen wound dressing 1 gram was observed on the armoire unattended. On 06/12/2024 at 10:35 AM, Certified Nursing Assistant (CNA) #10 revealed during an interview that collagen powder and iodine swabs should be stored in the wound care cart. On 06/12/2024 at 10:46 AM, Licensed Practical Nurse (LPN) #8 revealed during an interview that collagen powder and iodine swabs should be locked up in the treatment/wound cart when not in use. On 06/12/2024 at 11:52 AM, the Director of Nursing (DON) revealed during an interview that collagen powder and iodine swabs should be in the wound care cart because we don't want them (the residents) to access it. 2. On 06/11/2024 at 11:05 AM, the surveyor accompanied Registered Nursing (RN) #1 to the medication room on 100/200/300 Hall. RN #1 reached in the refrigerator and pulled out the red narcotic box. RN #1 said, That is supposed to be locked. The following medications were identified inside the narcotics box by RN #1: a. Ativan 2mg/ml (milligram/milliliter), 30 ml unopened vial. b. Ativan oral concentrate 1mg/0.5ml- 5 syringes On 06/11/2024 at 11:09 AM, RN #1 told the Surveyor the narcotic box will not lock. RN #1 was asked why it would be important to lock the narcotic box, and how many locks should the narcotic box be behind. RN #1 said the narcotic box should be behind at least 2 locks, and not being locked appropriately would give anyone that came into the medication room access to the controlled medications. On 06/12/24 at 10:40 AM, the Surveyor received a copy of a letter dated 06/01/2024 indicating the narcotic box was not working in the medication room. On 06/12/24 at 11:44 AM, the Surveyor interviewed the Maintenance Supervisor (MS) and asked if he was aware the narcotic box lock had not been working in the 100/200/300 hall. The Maintenance Supervisor (MS) said he was aware, and the Administrator was aware and had ordered the lock that was used to fix it. The MS confirmed that the narcotic box lock in the other medication room was not affected. On 06/12/2024 at 11:45 PM, the Director of Nursing (DON) was asked if leaving medication at the bedside was a standard of practice and why. The DON told the Surveyor that it is not standard practice, and another resident could get the medications. When asked if the facility has any residents approved for self-administration, the DON confirmed they did not. The DON confirmed the narcotic box should be behind at least two locks, because less than that would cause a risk of easier access if someone wanted it, and the facility does not have any residents with self-administration rights. On 06/12/2024 at 12:57 PM, the Administrator provided a policy titled Medication Storage in the Facility documenting, .Policy Medications and biologicals are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures .Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized use .Except for those requiring refrigeration or freezing, medications intended for internal use are stored in a medication cart or other designated area. 3. The policy titled Medication, General Administration of indicated, Procedure 1, Drugs and biologicals may be administered only by licensed physician, licensed registered or practical nursing personnel, or by other personnel who are duly authorized to perform such services under state law .Self-Administration of drugs is permitted when approved by the interdisciplinary team and with a physician's order . On 06/12/2024 at 2:00 PM, The DON provided a policy titled Medications, Self-Administration of documenting, General Guidelines 1. A resident may be permitted to administer or retain medication in his/her room under the following conditions: a. Assessment and approval by the interdisciplinary team . Reveal of the Medical Diagnosis portion of Resident #72's electronic health record revealed diagnoses of respiratory failure, cerebral infarction, and dysphagia. The Quarterly MDS with an ARD of 03/09/2024 indicated a BIMS score of 15 (13-15 suggest cognitively intact). On 06/11/2024 at 8:30 AM, while observing a tube feed change, Licensed Practical Nurse (LPN) #2 walked out of a room leaving a bottle of nasal spray and a corticosteroid inhaler resting on a bedside table across the room from Resident #72. Three 100 ml (milliliter) bottles of 0.9% sodium chloride were noted on the right bedside table. LPN #2 returned to Resident #72's bedside to hang tube feeding. On 06/11/2024 at 8:50 AM, LPN #2 left the room, leaving the nasal spray and corticosteroid inhaler resting on a bedside table across the room from Resident #72, and three 100 ml bottles of 0.9% sodium chloride resting on the right bedside table. On 06/11/2024 at 8:52 AM, the Surveyor asked LPN #2 about the three bottles of Sodium Chloride sitting at the bedside and was told those stay in the room to flush the resident's catheter every 4 hours. When asked about the nasal spray and the inhaled corticosteroid, LPN #2 said, That was me I forgot to take it out with me. During the interview, LPN #2 was asked why it was important not to leave medication in resident rooms. LPN #2 said in case they get up and consume it or another resident wanders in. LPN #2 confirmed the new resident across the hall wanders out sometimes. 4. Review of the Medical Diagnosis portion of Resident #342's electronic health record revealed diagnoses of bone neoplasm, hematuria, and mood disorder. The Admission MDS with an ARD of 05/23/2024 indicated a BIMS score of 15 (13-15 indicates cognitively intact). On 06/10/2024 at 11:57 AM, while in Resident #342's room the Surveyor observed an open, undated bottle of 0.9% sodium chloride resting on the right side of the bathroom sink. On 06/11/2024 at 4:45 PM, LPN #2 identified the open bottle of 0.9% sodium chloride resting on Resident #342's bathroom sink. The Surveyor asked LPN #2 why there would be an open bottle of sodium chloride in the room. LPN #2 pointed out Resident #342 has an order for PRN (as needed) catheter flushes. The Surveyor asked if it was a standard practice to leave an open, undated bottle of sodium chloride in a resident's room. LPN #2 told the Surveyor that nobody should be leaving any medication in resident rooms, and confirmed there would be a risk for the resident or other residents that wander in the building to consume the medication. LPN #2 has pointed out that a new resident near Resident #342's room has wandered out into the hallway.

Based on record review, observations, and interviews the facility failed to ensure hand hygiene/change gloves was performed to prevent the spread of disease and or infections during meal service for 1 (Resident #26) of 1 sampled residents; and failed to ensure hand hygiene was performed during medication administration for 2 (Resident #69 and #392) of 2 sampled residents; and failed to ensure hand hygiene / change gloves was performed and clean items were not contaminated during incontinent care for 2 (Resident #82 and #28) of 2 sampled residents. The findings are: Review of a facility policy, Handwashing/Hand Hygiene, dated 11/22/2017, revealed, This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. An alcohol-based hand rub may be used if no visible soiling. Hand hygiene is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of a facility policy, Standard Precautions, dated 11/22/2016, revealed, Standard precautions will be used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except swear), non-intact skin and mucous membranes may contain transmissible infectious agents. Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Wash hand immediately after gloves are removed, between resident contact, and when otherwise indicated to avoid transfer of microorganisms to other residents or environments. Wash hands between tasks and procedures on the same resident to prevent cross-contamination of different body sites. Wear gloves (clean, nonsterile) when touching blood, body fluids, secretions, excretions, and contaminated items. Change gloves between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another residents. Handle resident-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of other microorganisms to other residents and environments. 1. A review of an Admission Record indicated the facility admitted Resident #26 with a diagnosis of dementia. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/15/2024, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 2 , which indicated the resident had severe cognitive impairment. Resident #26 required setup or clean-up assistance for eating. A review of Resident #26's Physician Orders, for the month of 05/2024, revealed an order, dated 12/07/2022, to admit to long term care secured unit related to dementia and elopement risk. A review of Resident #26's Care Plan, revised 02/17/2023, revealed the resident had an activity of daily living (ADL) self-care performance deficit related to dementia; with an intervention that included requiring limited assistance of one staff for eating; revised on 02/17/2023. On 06/10/2024 at 12:32 PM, Certified Nursing Assistant (CNA) /Unit Manager picked up a container of ice cream off the secure unit dining room floor and disposed it into the trash. CNA / Unit Manager walked to the sink and obtained a paper towel, wiped hand, then obtained a new container of ice cream from the refrigerator freezer and placed it on the table to the right side of Resident #26. CNA / Unit Manager did not perform hand hygiene. On 06/10/2024 at 12:38 PM CNA / Unit Manager began to assist Resident #26 with meal service. CNA / Unit Manager did not perform hand hygiene. 2. Review of an Admission Record indicated the facility admitted Resident #69 with a diagnosis of hypothyroidism. The Annual MDS with an ARD of 03/29/2024, revealed Resident #69 had a BIMS score of 3, which indicated the resident was severely cognitively impaired. A review of Resident #69's Physician Orders, for the month of 06/2024, revealed an order, dated 09/19/2023, for levothyroxine sodium (a thyroid medication) 88 micrograms (mcg), one tablet in the morning for hypothyroidism (low thyroid). 3. Review of an Admission Record indicated the facility admitted Resident #392 with a diagnosis of hypothyroidism. The Admission MDS with an ARD of 05/26/2024 revealed Resident #392 had a BIMS score of 15, which indicates the resident was cognitively intact. A review of Resident #392's Physician Orders, for the month of 06/2024, revealed an order, dated 05/22/2024, for levothyroxine sodium 25 mcg, one tablet in the morning for hypothyroidism. On 06/12/2024 at 5:50 AM, Registered Nurse (RN) #6 was observed preparing medications for administration for Resident #69, levothyroxine 88 mcg x 1 tablet (green in color). RN #6 did not perform hand hygiene before punching out medication from the bubble pack card. On 06/12/2024 at 5:56 AM, RN #6 entered Resident #392's room carrying both medicine cups containing one pill each. RN #6 turned on the over bed light and gave Resident #392 a medicine cup containing the pink pill. RN #6 did not perform hand hygiene before entering the room. RN #6 turned off the overhead light and exited the room. RN #6 did not perform hand hygiene when exiting the Resident's room. RN #6 walked into Resident #69's room carrying a medicine cup containing 1 green pill. RN #6 picked up Resident #69's water pitcher and shook it, sat it back down on the bedside table and walked out of the room and obtained a plastic cup from the medicine cart. RN #6 did not perform hand hygiene upon exiting the room or obtaining the plastic cup. RN #6 walked back into Resident #69's room. RN #6 did not perform hand hygiene. RN #6 poured water into the plastic cup from R #69 water pitcher. RN #6 raised Resident #69's head of the bed using the remote control and administered the Resident's medication. RN #6 lowered Resident's head of bed using the remote control and placed the unused water cup on the bedside table. RN #6 then exited Resident's room. RN #6 did not perform hand hygiene after exiting the room. On 06/12/2024 at 6:00 AM, RN #6 began charting in the laptop on top of the medication cart. RN #6 picked up a stack up medicine cups on the medication cart and started with the next medication pass. On 06/12/2024 at 6:08 AM, RN #6 was asked when do you perform hand hygiene and why. RN #6 stated, Most of the time, I try to remember to do it when I come out of their room and before going to the next room, to eliminate bacteria from being transferred. On 06/12/2024 at 11:52 AM, the Director of Nursing (DON) was asked when hand hygiene is performed during medication administration. The DON stated, Between each patient. 4. A review of an Admission Record indicated the facility admitted Resident #82 with a diagnosis that included Alzheimer's disease. The Annual MDS with an ARD of 03/29/2024 revealed Resident #82 had a BIMS score of 5, which indicated the resident was severely cognitively impaired. The resident required substantial/maximal assistance for toileting and personal hygiene. On 06/11/2024 at 8:46 AM, Resident #82 was observed having wet pants. Certified Nursing Assistant (CNA) #7 was observed to assist the resident to their room. CNA #7 went across the hall, then entered Resident #82's room and applied gloves. CNA #7 did not perform hand hygiene before applying the gloves. CNA #7 assisted Resident #82 into the bathroom in the Resident's room. CNA #7 pulled Resident #82's pants down to the bathroom floor exposing bowel movement in the brief. CNA #7 had Resident #82 sit on the toilet. CNA #7 removed their gloves and applied new gloves. CNA #7 did not perform hand hygiene. CNA #7 tore the side of the brief from Resident #82 and pulled the brief between Resident #82 legs and placed in a plastic bag in the trash can. CNA #7 removed the plastic bag from the trash can and placed the plastic bag with soiled brief in Resident #82's bathroom floor. CNA #7 did not change gloves and did perform hand hygiene. CNA #7 removed Resident # 82's shoes with the same dirty gloves, placed the shoes to the side in the floor, then removed Resident #82's pants, and placed the soiled pants into a plastic bag in the trash can. CNA #7 did not change gloves and did not perform hand hygiene. With the same contaminated gloves, CNA #7 removed a pre-moistened wet wipe from the package and wiped Resident # 82 heels, then discarded the pre-moistened wet wipe into the plastic bag with the soiled brief on the floor. With contaminated gloves, CNA #7 placed the package of pre-moistened wet wipes on the floor between Resident #82's legs. Using both gloved hands, CNA #7 obtained a pre-moistened wet wipe and wiped the back of Resident # 82 legs removing feces and discarded. CNA #7 left the package of pre-moistened wet wipes on the floor. On 06/11/2024 at 8:53 AM, CNA #7 picked up the package of pre-moistened wet wipes from the floor and placed the package on top of Resident #82's clean brief and pants lying on the bathroom sink. Using both gloved hands, CNA #7 picked up the package of pre-moistened wet wipes and removed a wet wipe, wiped Resident #82, and discarded it into the plastic bag of soiled items in the bathroom floor. With both gloved hands, CNA #7 picked up a partial roll of toilet paper located on the back of the toilet and tore the toilet paper from the roll and placed the roll on the back of the toilet and continued to clean Resident #82, discarding the soiled toilet paper into the toilet and onto the clear plastic bag of soiled items on the floor. On 06/11/2024 at 8:56 AM, a clear plastic bag containing feces soiled brief, feces soiled pre-moistened wet wipes, and feces soiled toilet paper was observed to be overflowing on the bathroom floor. On 06/11/2024 at 8:57 AM, CNA #7 removed the contaminated brief from the bathroom sink and applied the brief over Resident #82's feet, pulling it up to Resident #82's calves. CNA #7 removed the contaminated pants from the bathroom sink and applied the pants over Resident #82 feet, pulling it up to the residents' calves. CNA #7 applied a house shoe on Resident #82 left foot, then applied a house shoe on Resident #82 right foot. CNA #7 pulled Resident #82's brief and pants up to the knees. CNA #7 did not change gloves and did not perform hand hygiene. On 06/11/2024 at 8:58 AM, CNA #7 instructed Resident #82 to stand up in front of the toilet. With the same contaminated gloved hands, CNA #7 picked up a partial roll of toilet paper from the back of the toilet and cleaned Resident # 82. Resident # 82 pulled brief up and pants. CNA #7 gathered the clear plastic bag of dirty trash from the floor. On 06/11/2024 at 9:09 AM, CNA #7 revealed during an interview that hand hygiene was to be performed, before interaction with a patient, wash hands, apply gloves, take to the restroom, removed the soiled clothing/linens, put in trash bags and wash hands, apply gloves and do peri-care, then after peri-care, wash hands, apply new gloves and put on new clothing. CNA #7 revealed that gloves should be changed, anytime you come in contact with soiled items. CNA #7 was asked where packages of wipes are usually placed when performing incontinent care. CNA #7 stated, They are usually in the bathroom on the counter or back of the toilet, they are not supposed to be on the floor. CNA #7 was asked where contaminated items were usually placed when performing incontinent care. CNA #7 stated, It goes in the trash bag in the trash can, not in the floor. CNA #7 was asked why contaminated / dirty items should be separated from clean items. CNA #7 stated, we don't want any bowel movement, urine, or germs on the patient. On 06/12/2024 at 11:52 AM, the DON revealed during an interview that soiled briefs and packages of pre-moistened wipes should not be in the floor due to contamination, hand hygiene should be performed before starting any tasks, between tasks, and after tasks. On 06/12/2024 at 3:21 PM, the Assistant Director of Nursing (ADON) / Infection Control Preventionist (ICP) revealed during an interview that packages of pre-moistened wipes used for incontinent care, should not be placed in the floor due to the floor is dirty, staff should wash or sanitize hands before applying gloves, and that soiled briefs and wipes should be placed in the trash bag in the trash can during incontinent care, and contaminated items should be kept separate from the clean items due to cross contamination purposes. 5. A review of a facility policy titled, Handwashing/Hand Hygiene, dated 11/22/2017, indicated, This facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .An alcohol-based hand rub may be used if no visible soiling .Hand hygiene is the final step after removing and disposing of personal protective equipment (PPE). 6. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with the routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. A review of a facility document titled, CARE Academy, revealed CNA # 3 received training on Application of Briefs, Infection Control, Hand Hygiene Competency, and Hand Hygiene Competency - Check off on 01/10/2024; Return Demo - Incontinent Care on 01/11/2024. A Review of a facility document titled, CARE Academy, revealed CNA # 4 received training on Infection Control, Hand Hygiene Competency, and Application of Briefs on 10/31/2023; All staff Hand Hygiene Competency - Check off and Return Demo - Incontinent Care on 01/17/2024. A review of a facility procedure titled, Perineal/Incontinence Care, with a revised date of 11/22/2016, indicated, .Procedure .Wash and dry hands .Apply clean pair of gloves .Assist resident over to one side and cleanse the anus and coccyx area .Change gloves .wash hands thoroughly . A review of the Admission Record, indicated the facility admitted Resident #28 with diagnoses that included hypothyroidism, vitamin D deficiency, vascular dementia, obstructive sleep apnea, disorders of bone density and structure, repeated falls, and aphasia. The Quarterly MDS with an ARD of 05/07/2024 revealed Resident #28 had a Staff Assessment of Mental Status (SAMS) score of 3, which indicated the resident had severe cognitive impairment. Resident #28 was dependent on staff for bed mobility, transfer, dressing, eating, toilet use, bathing, and personal hygiene. Resident #28 used a wheelchair for locomotion with the assistance of staff. A review of Resident #28's Care Plan initiated 01/27/2023, revealed the resident had a self-care deficit and was dependent on staff for dressing, eating, oral care, personal hygiene, toilet use, and transfer. Interventions included, encourage resident to participate to the fullest extent possible. Monitor for changes and potential improvement, to maintain or improve current level of function. A review of Order Summary Report, revealed Resident #28 had an order Call with any concerns for UTI symptoms .Methenamine Hippurate Oral tablet . related to urinary tract infection . During an observation on 06/10/2024 at 2:46 PM, CNA #3 and CNA #4 performed incontinence care for Resident #28. The CNAs did not perform hand hygiene or a glove change during the brief change when moving from a dirty task to a clean task of placing the clean brief on resident and repositioning, providing pillows, and covering with bed linens. On 06/10/2024 at 4:15 PM, CNA # 4, was asked what should have been done when moving from a dirty task to a clean task. CNA #4 stated both CNAs should have done hand hygiene and a glove change. CNA #4 stated it was unsanitary and could cause a resident to have an infection. On 06/12/2024 at 11:50 AM, the DON was asked how often staff should check on residents and changing briefs. The DON stated staff should be checking residents at least every 2 hours. The DON was asked if hand hygiene and glove changes should be done, during a brief change, when moving from cleaning of the perineal area and removing a soiled brief to placing a new brief on resident and performing hand hygiene after completion of the brief change. The DON stated CNAs should be performing hand hygiene and glove changes to prevent cross contamination and prevent urinary tract infections (UTI). On 06/12/2024 at 1:19 PM, the Administrator was asked if CNAs should perform hand hygiene and gloves changes during brief changes with perineal care. The Administrator stated CNAs should change gloves and wash hands to prevent contamination of clean brief because of UTIs caused by bacteria like E. coli (Escherichia coli, gram negative bacterium) that could be found. On 06/12/2024 at 1:19 PM, Administrator was asked what Care Academy documents were. CNA Coordinator stated, It is a competency training program built for staff, using CMS competencies. Staff must score 100 percent in each area and do a return demonstration to work here. They begin the training upon hire. On 06/12/2024 at 1:24 PM, CNA #3 was asked what should have been done during the brief change with perineal care for Resident #28. CNA # 4 stated, We should have laid out the items on a clean surface, had bags and we did not change our gloves and did not do handwashing. I got with our lead CNA and reviewed the process again.

49866 Based on record review, observations, and interviews, the facility failed to maintain a safe and functional environment to prevent possible injury, as evidenced by failure to ensure a night light cover was provided for 2 (Resident #33 and #92) of 2 sampled residents; and failed to ensure the vinyl flooring was maintained on the 300 hall secure unit. The findings are: On 06/10/2024 at 1:57 PM, the doorway threshold in room [ROOM NUMBER] had 42 inches by 2 inches of vinyl tile missing, leaving a gap in the floor. The doorway threshold in room [ROOM NUMBER] had black electrical tape peeling and loose. There was a 1/4-inch gap. On 06/10/2024 at 1:59 PM, the doorway threshold in room [ROOM NUMBER] had 6 inches by 2 inches of vinyl tile missing, leaving a gap in the floor. On 06/10/2024 at 2:00 PM, the doorway threshold in room [ROOM NUMBER] had 6 inches by 2 inches of vinyl tile missing, leaving a gap in the floor. On 06/12/2024 at 5:11 AM, the doorway threshold in room [ROOM NUMBER] had 6 inches by 2 inches of vinyl tile missing, leaving a gap in the floor. On 06/12/2024 at 5:12 AM, the doorway threshold in room [ROOM NUMBER] had 6 inches by 2 inches of vinyl tile missing, leaving a gap in the floor. On 06/12/2024 at 5:13 AM, the doorway threshold in room [ROOM NUMBER] had black electrical tape peeling and loose. There was a 1/4-inch gap. On 06/12/2024 at 5:14 AM, the doorway threshold in room [ROOM NUMBER] had a 42 inch by 2 inch section of vinyl tile missing, leaving a gap in the floor. On 06/12/2024 at 2:10 PM, Certified Nursing Assistant (CNA) #7 revealed during an interview that the process for reporting things that needed to be repaired in the facility was to put an order in the drop box for maintenance, and she had not reported any flooring that needed repaired. CNA #7 described the floor tile/threshold vinyl tile in room [ROOM NUMBER] as missing leaving a gap, in room [ROOM NUMBER] a piece was missing leaving a gap, and in room [ROOM NUMBER], black tape is coming up with a gap exposed. CNA #7 revealed that the areas to the floor had been there a little bit, and it could potentially cause a fall. On 06/12/2024 at 2:20 PM, Licensed Practical Nurse (LPN) #8 revealed during an interview the process for reporting things that needed to be repaired in the facility was to place a work order in the black box for maintenance, and she had not reported any flooring that needed repaired, and that it should be reported to maintenance because it was a hazard. On 06/12/2024 at 2:34 PM, the Maintenance Supervisor revealed during an interview, the process for reporting things that needed to be repaired in the facility was to place a work order in either box located at each nurses' station or the maintenance office. They make rounds every day in the facility and check the boxes every day and the areas to the floor on the 300 hall had not been reported. The Maintenance Supervisor was asked to measure the areas in the floor in room [ROOM NUMBER], 307, 310, and 311. Maintenance Supervisor measured room [ROOM NUMBER]: 6.5 inches by 2 inches and missing a piece of vinyl floor leaving a gap in the floor. room [ROOM NUMBER]: 6.5 inches by 2 inches and missing a piece of vinyl flooring, leaving a gap in the floor. room [ROOM NUMBER]: the tape is coming up and there's a 1/8th of an inch gap in the flooring. room [ROOM NUMBER]: 43 inches by 2 inches and missing a piece of vinyl flooring, leaving a gap in the floor. The Maintenance Supervisor revealed that the missing pieces of vinyl flooring would be a trip hazard.

Based on interviews, record review, and facility document review, it was determined the facility failed to coordinate with the state designated office to get evaluation of resident to ensure resident received designated services for 1 (Resident #44) of 2 resident reviewed for Preadmission Screening and Resident Review (PASARR). Findings include: A review of the [State Designated Professional Associates], letter dated 06/16/2023, indicated Resident #44, Has been approved for nursing home placement by OLTC (Office of Long-Term Care) and may enter nursing home of his/her choice. The letter instructed the facility, You must contact [State Designated Professional Associates] with the Client's admitted in order to receive your client's completed PASARR evaluation. A review of the Admission Record, indicated the facility admitted Resident #44 on 06/27/2023 with diagnoses that included schizophrenia and other recurrent depressive disorders. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/04/2023, revealed Resident # 44 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. Section I, Active Diagnoses, subtitle Psychiatric/Mood Disorder, included I5800 Depression and I6000 Schizophrenia. Section N Medications, N0410 Medications Received indicated in the last 7 days, resident received an antipsychotic 7 days, received an antidepressant 7 days, and received a hypnotic 7 days; N0450 Psychotic Medication Review, A. indicated resident received antipsychotics on a routine basis. A review of Resident # 44's Care plan, revised 09/27/2023, revealed the resident had the potential to be verbally aggressive related to the diagnosis of schizophrenia. Interventions included monitoring behaviors, Psychiatric/Psychogeriatric consult as indicated, and administering medications as ordered. The Care Plan with a revision date of 11/17/2023 revealed The resident uses psychotropic medications r/t (related to) schizophrenia, recurrent depressive disorders, pain. Interventions included discussing with physician and family ongoing need for medication and review of behaviors and interventions and alternate therapies attempted and their effectiveness. During an interview on 06/11/2024 at 3:03 PM, the Administrator was asked who was responsible for coordinating admissions ensuring PASARRs were completed. The Administrator stated the Admission Coordinator is responsible. During an interview on 06/11/2024 at 3:05 PM, the Admission Coordinator was asked if the State Designated Professional Associate was notified of the admitted for Resident # 44 as instructed in the letter. The Admission Coordinator was unable to respond, stating, I will check with the Administrator. The Admission Coordinator was asked if the completed PASARR was received, the Admission Coordinator was unable to respond, stating, I will check with the Administrator. On 06/11/2024 at 3:22 PM, the Admission Coordinator stated, Notification to [State Designated Professional Associates] was not made with the admitted . The Admission Coordinator was asked what guidance is followed when admitting a resident and obtaining a PASARR. The Admission Coordinator stated, I will need to ask the Administrator. During an interview on 06/11/2024 at 4:04 PM, the LTC (Long Term Care) MDS was asked what guidance is followed when completing the MDS for residents. LTC MDS stated, I look at the MISC, (Referring to the Miscellaneous area in the Facility Computer Software Program used by the facility for documenting on residents.) tab and see if there has been a change in condition or if there is a PASARR. The LTC MDS was asked if Section A1500 of the admission MDS dated [DATE] is correct looking at the State Designated Professional Associates letter. LTC MDS stated, Based on what the MISC info contains, I am not able to accurately respond, and I have not seen that letter. The LTC MDS was asked what the RAI manual is used for, and responded if there are any questions that cannot be answered or if there is a new diagnosis code in the change of condition, we can look at it. When the surveyor asked if it contains guidance on completing A1500 or PASARR instructions, LTC MDS stated, No it does not have anything to do with the PASARR, I have looked. Surveyor asked the LTC MDS to look at the RAI Manual. The LTC MDS opened an electronic version of the RAI Manual on desktop computer. The screen opened immediately to A1500, without search. I never saw this before. I use my notes from the classes I have taken and I don't use the RAI. I do have the RAI manual book. It is here and there are some notes in it. LTC MDS was unable to respond to question regarding the State Designated Professional Associates letter or follow up of the letter. LTC MDS stated the admission process is done through another employee for PASARR. On 06/12/2024 at 07:51 AM, the LTC MDS provided a copy of the A1500 Preadmission Screening and Resident Review section of the RAI Version 3.0 Manual which indicates .All individuals who are admitted to a Medicaid nursing facility must have a Level I . PASARR, . Individuals who have or are suspected to have MI (mental illness) . may not be admitted to a Medicaid-certified nursing facility unless approved through Level II . PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provide by the State . Planning of Care The Level II PASRR determination and the evaluation report specify services to be provide by the home and/or specialized services defined by the State .The services to be provided by the nursing home and /or specialized services provided by the State that are specified in the Level II PASRR determination and the evaluation report should be addressed I the plan of care .Steps for Assessment .2. Review the Level I PASRR .3. Review the PASRR report provided by the State if Level II screening was required .

Based on observation, record review, and record review the facility failed to ensure that oxygen order included parameters for 1 of 1 Resident #12 receiving oxygen to prevent respiratory complications. The findings are: 1. Review of the Medical Diagnosis portion of Resident #12's electronic health record revealed diagnoses of heart failure, chronic kidney disease, and type 2 diabetes mellitus. a. Review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/22/2024 revealed a Brief Interview for Mental Status (BIMS) score of 6 (0-7 indicates severe cognitive impairment). b. Review of a Physician's Order dated 01/29/2024 revealed, Oxygen PRN (as needed) for SAT (oxygen saturation) under 90 as needed for shortness of breath and low SAT. c. On 06/10/2024 at 11:29 AM, Resident #12 was observed receiving oxygen at 1.5 liters via nasal cannula. d. On 06/11/2024 at 8:30 AM, Resident #12 was observed receiving oxygen at 1.5 liters via nasal cannula. e. On 06/12/2024 at 01:35 PM, Resident #12 was observed to be receiving oxygen at 1.5 liters via nasal cannula. f. On 06/12/2024 at 1:41 PM, the Director of Nursing (DON) was asked what the standard of practice is for oxygen orders regarding parameters. The DON told the surveyor that oxygen orders had to have parameters, because staff cannot just keep going up and up on the oxygen for residents. Too much oxygen can be bad. g. On 06/12/2024 at 2:00 PM, the DON provided a policy titled Oxygen Safety that did not address oxygen parameters.

Based on observation, record review, and interview, the facility failed to ensure a thorough assessment was performed to determine possible injuries after a fall, physician orders [REDACTED].#69) who was wearing a fiberglass cast. These failed practices had the potential to affect 46 residents who had a history of [REDACTED]. 1. Resident #69 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/25/2020 documented the resident scored 3 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS); required supervision with bed mobility and transfers; required limited assistance with personal hygiene, dressing, and toilet use; was occasionally incontinent of bladder and of bowel; had no falls prior to admission; had one fall without injury since admission or last assessment; required no scheduled or as needed pain medication; and did not require a pain assessment to be conducted. a. A facility Nursing Incident and Accident Note dated 10/3/2020 documented, .Heard resident screaming coming from her room while I was charting in the Dining Room. Upon entry, resident was laying in bathroom floor on her left side with knees bent. No obvious injuries. During assessment, resident stated her left side hurt and also her left foot. Resident could give no description to what happened. Resident was placed in bed per two-person assist (assistance). Neuros (Neurological checks) started. Called (Name) (at) 0515 (5:15 a.m.) to report fall. Notified (Name) (at) 0530 (5:30 a.m.). Called (Name) resident's daughter at 0535 (5:35 a.m.). Put resident on q (every) 2 H (hour) toileting and wake if asleep. Also, Orthostatic BP (blood pressure) for 72 H (hours) Q (every) shift . b. A facility Incident and Accident Report for an Unwitnessed Fall dated 10/3/2020 at 5:00 a.m. documented, .Immediate Action Taken . Put resident on q2h (every 2 hours) toileting and wake if asleep. Orthostatic BP (blood pressure) for 72 H (hours) Q (every) Shift . c. A physician's orders [REDACTED].Stat (Immediate) x-ray to left hip due to fall rt (related to) pain . d. A Nursing Incident and Accident Note dated 10/3/2020 at 20:14 (8:14 p.m.) documented, .At 0830 (8:30 a.m.) this nurse noticed resident going to stand from dining table after eating breakfast to leave Dining Room. This nurse was at another table giving meds (medications) to another resident when a loud noise was noted. Resident had turned a chair over and was falling. At the same time, a CNA (Certified Nursing Assistant) entered the Dining Room. Resident was assessed for injury, pain. Resident was assisted with use of gait belt and two staff to standing position, then to a chair . e. An Incident and Accident Report for a Witnessed Fall dated 10/3/20 at 8:30 p.m. documented, .Immediate Action Taken . Assessed for pain, injury, neuro (neurological) checks were already in place from previous fall . Resident did not bump her head. CNAs notified to check resident q (every) 1 hour for assistance with transfers. Resident used WC (wheelchair) for mobility . f. A physician's orders [REDACTED].Obtain Orthostatic B/P (blood pressure) Q (every) Shift (times) 72 Hours every shift for 3 Days . g. The facility Vital Sign log dated October 2020 did not reflect Orthostatic blood pressures were obtained as documented on 10/3/20 at 5:00 a.m. h. The facility DON (Director of Nursing) / Designee Risk Management Investigation dated 10/5/2020 and signed by the Director of Nursing documented, .Documentation exists in the medical record for the following . 1. Head to Toe Assessment . i. A Physician's Progress Note dated 10/8/2020 at 11:12 a.m. documented, .PA Telehealth Visit . Today's visit is medically necessary for hip pain. Nursing staff report pt (patient) having increased left hip pain since her fall. Her x-ray was negative . Musculoskeletal . Motor Strength and Tone . Normal tone . Joints, Bones, and Muscles . No contractures or malalignment and tenderness and limited ROM (range of motion) . Extremities . No [MEDICAL CONDITION] . Back . Thoracolumbar Appearance . Normal curvature . Assessment / Plan . 1. [MEDICAL CONDITION] of Left Hip Joint . Start [MEDICATION NAME] prn (as needed) . Monitor for changes . Unilateral Primary [MEDICAL CONDITION], Left Hip . [MEDICATION NAME] 50 mg (milligrams) tablet . Take 1 tablet(s) every 6 hours by oral route as needed . Qty (Quantity) . 45 tablet(s) . Refills . 0 . Pharmacy .(Name) . j. A Nurses Note dated 10/8/2020 at 1:38 p.m. documented, .R (Resident) continues to c/o (Complain of) pain to left lower extremity and doesn't bend her left knee when she walks. After further assessment, purple bruise noted to side of left ankle, swelling, and top of left foot. (Name), PA (Physician's Assistant) notified and received Order for 2 view x-rays of left foot and ankle . k The Medication Administration Record [REDACTED] l. A Nurse's Note dated 10/9/2020 at 9:01 a.m. documented, .R (Resident's) left ankle x-ray results in and resident has a fracture. Daughter, (Name) telephoned and unable to go with R (Resident) to ER (emergency room ). R (Resident) being sent by (Name) driver with female CNA (Certified Nursing Assistant) attending R (Resident) on the drive, as well as in the ER (emergency room ) . m. A Physician's Progress Note dated 10/9/2020 at 1:14 p.m. documented, .X-ray at the hospital showed Isolated Malleolus Fibular Fx (fracture) with 3mm (3 millimeter) displacement. She was placed in a soft cast . She is to follow-up with Ortho (Orthopedics) in a week . 10/14/2020 order for 3 view x-ray of left ankle on 10/21/2020 . Closed Fracture of Distal Left Fibula . Continue [MEDICATION NAME] prn (as needed) . Monitor for changes. F/u (Follow-up) with Ortho (Orthopedics) . n. A Hospital After Visit Summary / Report dated 10/14/20 documented, .Wearing a fiberglass cast . Care Instructions . When to call the doctor . There is a lot of swelling near the cast . You have a new fever . There is drainage or bad smell coming from the cast . Your foot is cool or pale or changes in color . You have trouble moving you toes . o. On 11/9/2020 at 12:00 p.m., the resident was lying in bed, and had a pink fiberglass cast applied to left lower extremity. p. As of 11/9/2020 at 12:24 p.m., the medical record contained no documentation related to cast care and monitoring. q. On 11/10/2020 at 12:49 p.m., Licensed Practical Nurse (LPN) #2 was asked, Why is the resident in a cast? LPN #2 stated, To be completely honest, I think she broke her ankle, but I am not certain because I haven't worked back here in a long time. LPN #2 was asked, Should the resident's lower extremity be assessed when a cast is in place? LPN #2 stated, If I was the nurse back here, I would. LPN #2 was asked, Should it be documented in the chart that the extremity has been assessed? LPN #2 stated, Yes. I would document it, especially since she is not in a state of mind to tell you if there is a problem. r. On 11/11/2020 at 10:37 a.m., the Director of Nursing (DON) was asked for documentation of every 2 hour toileting and orthostatic blood pressure monitoring as documented as an Immediate Action for the fall which occurred on 10/3/2020 at 5:00 a.m. and documentation of every 1 hour checks on the resident following the second fall on 10/3/2020 at 8:30 a.m. As of 11/11/2020 at 3:45 p.m., the information requested was not provided / received. s. On 11/11/2020 at 11:25 a.m., Licensed Practical Nurse (LPN) #4 was asked, Was the resident able to ambulate prior to her falls on 10/3/2020? LPN #4 stated, Yes. She walked without assistance but required supervision for safety reasons. LPN #4 was asked, Can you recall the resident falling? She stated, I believe it was a fall on the weekend. I remember doing a body audit on her the following Tuesday, I believe. There was no bruising noted to the foot. I did note bruising to the hip at that time. t. On 11/11/2020 at 12:34 p.m., the Director of Nursing (DON) was asked if she ever completed an assessment on the resident after she had the 2 falls on 10/3/2020. The DON stated, Only on the day we got the foot x-ray. I was doing rounds on the Unit and noticed her having trouble standing up, so I walked her to her room. I assessed her and noticed she had bruising to her foot, so I notified the APN (Advanced Practice Nurse). She was in the building, so she came down and assessed her. That is when we ordered the x-ray. The DON was asked, What follow up has been done since the resident was placed in a cast on 10/14/2020? The DON stated, She is seeing (Name) Ortho (Orthopedics). We took a disc of images over to them. The first disk did not have any images on it, so they had to get a new disk this week. I bet they have not scheduled her yet since they had ordered more x-rays. I do not think she has a follow-up appointment scheduled yet. I will have the PA (Physician's Assistant) look in their system to see when they want to follow-up. u. On 11/11/2020 at 2:16 p.m., LPN #5 was notified via telephone and was asked if she recalled the events on 10/3/2020 when the resident had 2 falls? LPN #5 stated, Before I got there, she had a fall. They had ordered an x-ray because she complained of hip and leg pain. Then in the Dining Room, around breakfast, she stood up and fell . A CNA was coming in the room, so I had her help me get her up into a chair. I don't think she said she was in any pain then, so we got her up. LPN #5 was asked, How did you perform a physical assessment on the resident? LPN #5 stated, I did neuro-checks (neurological checks) and I would go in and check on her often. It's always really busy. v. On 11/11/2020 at 3:48 p.m., the DON was asked, Should the resident with the cast on her lower leg have been assessed? The DON stated, Yes. It should have been assessed. The DON was asked, Is that a standard practice of nursing? The DON stated, Yes, it is. w. On 11/11/2020 at 4:30 p.m., the medical record contained no documentation of a head to toe assessment. The Director of Nursing was asked for the documentation of the head to toe assessment performed on 10/3/2020. As of 11/11/2020 at 3:45 p.m., the information requested of the Head to Toe assessment was not provided / received as requested. x. A facility policy titled Incident and Accident provided by the Director of Nursing on 11/11/2020 at 3:20 p.m. documented, .3. Prior to moving the injured person, the Charge Nurse will perform an assessment for possible injuries, including vital signs . If clinically indicated, all major joints (shoulders, elbows, wrist, hips, knee, and ankles) will be assessed by palpation and ROM (range of motion), even if there are no complaints referable to that joint. If clinically indicated, arrangements will be made for hospital transfer or x-ray .

Based on observation, record review, and interview, the facility failed to ensure pain was properly and thoroughly assessed to provide optimal comfort through pain control after 2 falls for 1 (Resident #69) of 1 sampled resident who was experiencing pain. This failed practice had the potential to affect 61 residents who were on pain management, according to the list provided by the Administrator on 11/11/2020 at 4:25 p.m. The findings are: 1. Resident #69 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/25/2020 documented the resident scored 3 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS); required supervision with bed mobility and transfers; required limited assistance with personal hygiene, dressing, and toilet use; was occasionally incontinent of bladder and of bowel; had no falls prior to admission; had one fall without injury since admission or last assessment; required no scheduled or as needed pain medication; and did not require a pain assessment to be conducted. a. The Care Plan dated 2/21/2020 documented, .Utilize Pain Assessment in Advanced Dementia Scale (PAINAD) to assess for pain / discomfort . b. A facility Nursing Incident and Accident Note dated 10/3/2020 documented, .Heard resident screaming coming from her room while I was charting in the Dining Room. Upon entry, resident was laying in bathroom floor on her left side with knees bent. No obvious injuries. During assessment, resident stated her left side hurt, and also her left foot. Resident could give no description to what happened. Resident was placed in bed per two-person assist (assistance). Neuros (neurological checks) started. Called (Name) 0515 (5:15 a.m.) to report fall. Notified (Name) (at) 0530 (5:30 a.m.). Called (Name) resident's daughter at 0535 (5:35 a.m.). Put resident on q (every) 2 H (hour) toileting and wake if asleep. Also, Orthostatic BP (blood pressure) for 72 H (hours) Q (every) shift . c. A physician's orders [REDACTED].Stat (Immediate) x-ray to left hip due to fall rt (related to) pain . d. A facility Nursing Incident and Accident Note dated 10/3/2020 at 20:14 (8:14 p.m.) documented, .At 0830 (8:30 a.m.) this nurse noticed resident going to stand from dining table after eating breakfast to leave Dining Room. This nurse was at another table giving meds (medications) to another resident when a loud noise was noted. Resident had turned a chair over and was falling. At the same time, a CNA (Certified Nursing Assistant) entered the Dining Room. Resident was assessed for injury, pain. Resident was assisted with use of gait belt and two staff to standing position, then to a chair . e. A Nursing Note dated 10/4/2020 at 10:47 a.m. documented, .Resident noted to be on follow-up post falls (times) 2 on 10/3/2020. Resident is requiring two staff with transfers. Resident c/o (complained of) left leg pain to staff, but when this nurse entered the room and asked resident, resident stated she was not in pain. Resident noted to yell at times with care. Resident has been noted to get up and take self to the bathroom without any difficulties. PA (Physician's Assistant) aware . f. A Physician's Progress Note dated 10/8/2020 at 11:12 a.m. documented, .PA Telehealth Visit . Today's visit is medically necessary for hip pain. Nursing staff report pt (patient) having increased left hip pain since her fall. Her x-ray was negative . Musculoskeletal . Motor Strength and Tone . Normal tone . Joints, Bones, and Muscles . No contractures or malalignment and tenderness and limited ROM (range of motion) . Extremities . No [MEDICAL CONDITION] . Back . Thoracolumbar Appearance . Normal curvature . Assessment / Plan . 1. [MEDICAL CONDITION] of Left Hip Joint . Start [MEDICATION NAME] prn (as needed) . Monitor for changes . Unilateral Primary [MEDICAL CONDITION], Left Hip . [MEDICATION NAME] 50 mg (milligrams) tablet . Take 1 tablet(s) every 6 hours by oral route as needed . Qty (Quantity) . 45 tablet(s) . Refills . 0 . Pharmacy .(Name) . g. A physician's orders [REDACTED].[MEDICATION NAME] HCl ([MEDICATION NAME]) Tablet 50 MG (milligrams) Give 1 tablet by mouth every 6 hours as needed for Hip Pain related to Pain . h. A Nurses Note dated 10/8/2020 at 1:38 p.m. documented, .R (Resident) continues to c/o (Complain of) pain to left lower extremity and doesn't bend her left knee when she walks. After further assessment, purple bruise noted to side of left ankle, swelling, and top of left foot. (Name), PA (Physician's Assistant) notified and received Order for 2 view x-rays of left foot and ankle . i. The Medication Administration Record [REDACTED] j. A Nurse's Note dated 10/9/2020 at 9:01 a.m. documented, .R (Resident's) left ankle x-ray results in and resident has a fracture. Daughter, (Name) telephoned and unable to go with R (Resident) to ER (emergency room ). R (Resident) being sent by (Name) driver with female CNA (Certified Nursing Assistant) attending R (Resident) on the drive, as well as in the ER (emergency room ) . k. A Physician's Progress Note dated 10/9/2020 at 1:14 p.m. documented, .X-ray at the hospital showed Isolated Malleolus Fibular Fx (fracture) with 3mm (3 millimeter) displacement. She was placed in a soft cast . She is to follow-up with Ortho (Orthopedics) in a week . 10/14/2020 order for 3 view x-ray of left ankle on 10/21/2020 . Closed Fracture of Distal Left Fibula . Continue [MEDICATION NAME] prn (as needed) . Monitor for changes. F/u (Follow-up) with Ortho (Orthopedics) . l. A physician's orders [REDACTED]. pain scale 0 to 10 every shift . m. On 11/11/2020 at 9:58 a.m., the Director of Nursing (DON) was asked, Why was no x-ray of the foot done after the resident complained of left side and foot pain following a fall? The DON stated, Because she got up and walked on it and wasn't complaining of pain. The DON was informed that the documentation stated that the resident complained of pain when found in the floor. The DON stated, I honestly don't know why we only x-rayed the hip and not the foot. n. On 11/11/2020 at 10:00 a.m., the Director of Nursing (DON) was asked, Why was the resident not treated for [REDACTED].? The DON stated, I'd have to talk to the nurses and see why. I don't know why she wasn't medicated. The DON was asked, Was [MEDICATION NAME] available in the Emergency Drug Box? The DON stated, I know we have it available, [MEDICATION NAME] 50 mg (milligrams). The DON was asked, Are the nurses aware the [MEDICATION NAME] is available in the Emergency Drug Box? The DON stated, Yes, the nurses know what is in the box. o. On 11/11/2020 at 11:25 a.m., Licensed Practical Nurse (LPN) #4 was notified by telephone and was asked about the resident's fall. LPN #4 stated, On Thursday I was on the Unit and saw her walking. She was not bearing weight on her left lower extremity. The DON and myself assisted the resident to her bedroom. I noticed her foot and ankle was very swollen and bruised. They did obtain a hip x-ray the day she fell , and they probably should have got an x-ray of her foot at that time as well. LPN #4 was asked, Did the resident ever complain of pain to you? LPN #4 stated, Yes. Whenever we were assisting her to bed she kept grabbing at her knee, and stated, 'Ouch'. After further assessment, we realized it was not her knee that was hurting her. LPN #4 was asked, Do you recall the resident ever complaining of pain prior to that incident? LPN #4 stated, Not that I can remember. If she did, I would have told the nurse. I am the Treatment Nurse, so I would have told the Charge Nurse. LPN #4 was asked, Did you tell the nurse about the pain when the resident did complain to you? LPN #4 stated, Yes. I told the nurse she complained of pain. LPN #4 was asked, Were you aware there were pain medications in the Emergency Drug Box? LPN #4 stated, Yes, absolutely. Actually, there are 2 boxes there in case one box did not have the medication needed. LPN #4 stated, When we laid her in bed, I knew there was something wrong since she was still complaining of pain. p. On 11/11/20 at 12:58 p.m., Certified Nursing Assistant (CNA) #1 was notified via telephone and was asked if she worked on the 7:00 a.m. to 3:00 p.m. shift on 10/3/2020. CNA #1 stated she worked 7:00 a.m. to 3:00 p.m. shift on 10/3/2020. CNA #1 was asked, Can you remember the resident falling on 10/3/202o? CNA #1 stated, I don't remember her falling. I do remember being back there on the Unit before she got her cast, and she told me that her foot was hurting. CNA #1 was asked, Did you tell the nurse? CNA #1 stated, Yes. I told the nurse. She was aware. CNA #1 was asked, Was the resident able to ambulate independently prior to the falls? CNA #1 stated, Yes, she was able to walk before her fall with supervision. After the falls it was hard for her to walk, so we put her in a wheelchair. q. On 11/11/2020 at 1:18 p.m., the Physician's Assistant was asked, Do you recall the events around the time of the resident's fall on 10/3/2020? The Physician's Assistant stated, Yes. It was a weekend fall. She (the resident) complained of hip pain, so I ordered an x-ray. It was negative, but she continued to complain of hip pain, so we started her on [MEDICATION NAME]. I was then notified of swelling in her foot, so we got an x-ray. The Physician's Assistant was asked, Did you visualize the foot? She stated, Yes. I visualized it myself, along with the DON, that is when I ordered the x-ray. When I examined her, she did not display any signs of being in pain. She was asked, Did you assess the resident for pain during your assessment? She stated, I pushed on her hip and it did not seem to hurt her. She was asked, Were you ever notified that the resident was complaining of foot or lower extremity pain? The Physician's Assistant stated, No. I was not notified of foot pain. r. On 11/11/2020 at 2:16 p.m., LPN #5 was asked, Do you recall the events on 10/3/2020 when the resident had 2 falls? LPN #5 stated, Before I got there, she had a fall. They had ordered an x-ray because she (the resident) complained of hip and leg pain. Then, in the Dining Room around breakfast, she stood up and fell . A CNA was coming in the room, so I had her help me get he up into a chair. I don't think she said she was in any pain then, so we got her up. LPN #5 was asked, Was there was a change in the resident's abilities to walk and perform ADLs (activities of daily living) after the falls? LPN #5 stated, She was weak. I remember using a wheelchair for her for a bit with her. We waited on the x-ray, and when it was negative, I thought she was just sore. LPN #5 was asked, Did the resident ever complain of pain to your? LPN #5 stated, Sometimes she said she was hurting, and sometimes she said she was not hurting. She would report to CNAs and sometimes the night nurse would say she was in pain, but when I would ask her, she would say, 'No'. LPN #5 was asked, Did the night nurse tell you that the resident complained of foot pain after the first fall? LPN #5 stated, I don't recall that they said foot pain specifically, but I think they said leg pain. It was not like she was crying out in pain all day. Whatever I documented is accurate. If she complained of pain, then I would have done something about it. I did go look at her leg when the CNA reported pain. LPN #5 was asked, Could a resident with Dementia state she is in pain at one time, and deny pain at another? LPN #5 stated, Sure they could. LPN #5 was asked, Could the resident have experienced pain while receiving care from the CNAs, such as transferring, toileting, and bed mobility, and not be experiencing pain while at rest, such as lying in the bed or sitting in the chair? LPN #5 stated, Well, sure they could. s. The facility policy titled Pain Management provided by the Director of Nursing on 11/11/2020 at 4:20 p.m. documented, .The purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family, and members of the Healthcare Team . Procedure . 4. Assess behavioral or visual indicators of pain if a resident is unable to verbally communicate .

Complaint # , substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to ensure close supervision was provided and interventions were promptly developed and implemented for a newly admitted resident who was a known high fall risk and had tried to get up without assist during the evening shift to prevent potential falls and reduce the potential for injury for 1 (Resident #16) of 11 (Resident #1 - 4, #6, #8 - 11, #15 and #16) case mix residents who were at high risk for falls. This failed practice resulted in actual harm to Resident #16, who fell and sustained a fractured leg, and had the potential to affect 71 residents who were at high risk for falls per a list provided by the Director of Nurses (DON) on 10/31/13 at 2:00 p.m. The findings are: 1. The Fall Prevention Program Policy documented: "... Patients placed in this program will be reassessed quarterly, after every fall occurrence, and upon change of condition. The following Guidelines may be initiated: ... 2. The Care Plan will be modified to reflect fall prevention measures. 3. Attending physician/pharmacy consultant will review chart and medications as necessary. 4. Low bed, bed and chair alarms will be utilized when applicable..." 2. Resident #16 was admitted to the facility on [DATE] at 5:30 p.m. with [DIAGNOSES REDACTED]. a. The Admission Nursing Assessment and History documented the resident was admitted on [DATE] at 5:30 p.m. The form documented the resident was accompanied by her husband and son. The form also documented the resident required 2-person assistance with transfers and ambulation; was weight bearing; used a wheelchair; was alert and oriented; continent of bowel and bladder and oriented to call light, facility and staff. b. The Admission Care Plan dated 8/1/13 documented, "...11. Falls/Safety Risk/Elopement Risk Goal: Resident will remain free of injury... Personal Alarm (circled)..." The care plan also documented bowel and bladder incontinence to assist with toileting by 2 persons as needed. c. The Fall Risk Assessment completed by Licensed Practical Nurse (LPN) #3 and dated 8/1/13 documented: "A. Level of Consciousness/Mental Status with a score of 2 (a score of 2 indicated disoriented x 3 at all times) B. History of Falls with a score of 2 (a score of 2 indicated 1-2 falls in past 3 months) C. Ambulation/Elimination Status with a score of 2 (a score of 2 indicated Chair Bound - and/or assist with elimination...) E. Gait/Balance with a score of 1 while standing (a score of 1 indicated balance problem while standing) a score of 1 while walking (a score of 1 indicated a balance problem while walking) a score of 1 with use of assistive devices (a score of 1 indicated use of assistive devices). G. Medications with a score of 4 (a score of 4 indicated takes 3 - 4 of these medications Anesthetics, Antihistamines, Antihypertensives, Anti-seizure, Benzodiazepines, Cathartics, Diuretics, Hypoglycemics, Narcotics, Psychotropics, Sedatives/Hypnotics). H. Predisposing Diseases with a score of 2 (a score of 2 indicates 1 - 2 of these predisposing diseases present: Hypertension, Vertigo, CVA (Cerebrovascular Accident), Parkinson's disease, Loss of limb(s), Seizures, Arthritis, Osteoporosis, fractures) TOTAL SCORE: 15 (Total score of 10 or above represents HIGH RISK for falls ..." d. The admission orders Oxycodone 10 mg (milligrams) (one) PO (by mouth) (every) 4 (hours PRN (as needed)... Pain, severe. Oxycodone 5 mg (one) PO (every) 4 (hours PRN ... Pain, moderate. Xanax 0.5 mg (one) PO (every) QID (4 times a day)..." e. Nurses Notes dated 8/1/13 at 5:30 p.m. and signed by Licensed Practical Nurse (LPN) #3 documented, "...Res. (Resident #16) arrived to facility from (Hospital) via APT (Private Vehicle) accompanied by Husband and Son. Res. is A (Alert) & (and) O (oriented) x (times) 3. Res. (with) c/o (complaint of) pain/discomfort (at) 1800 hrs. (6:00 p.m.), LUE (left upper extremity), LOP (level of pain) 10/10 (pain scale of 10 out of 10). Res. (with) facial grimace, guarding behaviors. T.O. (telephone orders) Hydrocodone 10/325 mg i (one) po x 1 Now/MD (medical doctor). At 19:30 (7:30 p.m.), "LOP 5/10, Res. sleepy/lethargic. Res refused further intervention... Res (with) increased confusion (at) 2100 hrs. (9:00 p.m.), A & O to self, Family stated Res would become confused when Xanax 0.5 mg i PO QID not given. 2200 hrs (10:00 p.m.) Res meds (medications) arrived, Xanax given, (no) confusion at 2300 hrs. (11:00 p.m.). 2300 hrs LOP 10/10, Oxy 10 mg i PO, LUE. 0000 hrs (12:00 a.m.) Res asleep in chair..." f. Nurses Notes dated 8/1/13 at 8:00 p.m. documented, "...Res. family requested pressure alarm to bed, pressure put in place activated and working. Res 2100 hrs (9:00 p.m.), Res A & O to self sitting on edge of bed, unsteady. Res agreed to sit in WC (wheelchair) (at) nurses station (with) staff for supervision. 2300 hrs. (11:00 p.m.), Res in bed longways, Nurse assisted Res on edge of bed to sit up per request. Res refused to sit in WC and to lay down in bed x 2. 0000 hrs (12:00 a.m.) nurse giving report to 3rd shift nurse, pressure alarm was activated (sounding) in the room. Res found standing turned and sat self in wooden chair next bed. Res refused to lay down or sit in WC x 2. Call light attached to Res night gown..." g. The Incident/Accident Report dated 8/2/13 at 0100 (1:00 a.m.) (page 1) completed by LPN #2 documented, "...Type of Injury: 7. Other Fx (fracture)..." Description of Incident: This nurse was notified by an aide to go into room (number). On scene I find (Resident #16) on the bathroom floor. There was another aide with her at that time. This nurse finds on assessment an open fracture on the LLE (left lower extremity). There was blood on the floor; though not significant... I obtained vital signs and found to be WNL (within normal limits) I asked the pt. (patient) what had happened. Pt. responded (with) low, soft and slow voice, "I don't know, I lost my balance and fell ". I notified her again about our call light system, to which she replied, 'I know'... Orders received: Send to ER (emergency room ) for tx (treatment) (and) eval. (evaluation). T.O. (Telephone Order) MD..." Page 2 documented, "Description of Incident by Person Injured:... 'I don't know I lost my balance and fell '... 3 - 11 nurse reported: (Resident #16) was brought to Nsg. (Nursing) station (after) family left because she kept trying to get up out of bed. At approx. (approximately) 11 pm (11:00 p.m.) (Resident #16) was taken back to room and placed in bed. The alarm sounded (at) 12 am (12:00 a.m.) and resident was found standing at bedside. She was placed in the chair at bedside per (Resident #16) request. At 12 AM 11 - 7 nurse introduced self offered to place in bed and resident refused. Call light was in reach. At 12:36 AM 2 aides were seen in camera in room and again at 1:00. (Resident #16) was found in bathroom (at) 1:18 AM per camera... Other Investigative Findings: In report with previous shift's nurse, I went in to the room (with) him to be introduced to pt (patient). She was sitting in her chair, and asked her if she'd like to go to bed. She refused. Resident's family had requested an alarm for her bed, but as stated, resident was on her chair. She had her call light in hand and was educated on our call light system and to not get up on her own... Her roommate is the only authorized user of the only walker in the room. Pt. had used it to go to the restroom... Steps To Prevent Reoccurrence: (Resident #16) sent to (hospital) ER (emergency room ) 911... Upon return place chair alarm..." h. The Witness Statement Form dated 8/1/13 at 0100 (1:00 a.m.), completed by CNA #2, documented, "At 0100 I walked down 200 hall, I heard an alarm sounding. It was coming from room (number). I entered the room (Resident #16's roommate) was standing. I helped her have a seat in her wheelchair. I then noticed that (Resident #16) was not in her bed or chair. I looked in the bathroom and she was laying on the floor. (Resident #16's) head was under a walker with her head against the walker and the wall. I removed the walker and noticed her left leg was against the toilet, her right leg was closer to the sink. I told the resident that I was going to get help and would be right back. I ran to find the nurse. I had another CNA go to the resident while I searched for the nurse. The nurse immediately went to assess the resident..." i. The Nurses Note dated 8/2/13 at 1:00 a.m. documented, "...N.O. (New Order) Send to ER for Eval (and) Tx. VTO (Verbal Telephone Order) MD..." j. Nurses Notes, late entry, dated 8/5/13 documented this nurse was notified by an aide to into room (room number). On scene I find (Resident #16) in the bathroom floor. There was another aide with her (at) the time. This nurse finds on assessment, open fracture on the LLE (left lower extremity)... I asked the pt (patient) what happened. Pt responded with low, soft, slow voice, 'I don't know I lost my balance & fell '... In report with previous shift nurse, I went into res room with him to be introduced to (Resident #16). She was sitting on her chair & asked her if she wanted to go to bed. She refused. Resident's family had requested an alarm in her bed, but as stated, the resident was in her chair. She had her call light in her hand & was educated on our call light system & not to get up on her own. On arrival refer eval (evaluation) of occupational & physical therapists, residents are to be assistance of two, then (after) eval they get whatever assistance device for ambulation & mobilization. Her roommate is the only authorized user of the only walker in the room. (Resident #16) had used it to go to the restroom. Physician notified, DON notified..." k. On 10/30/13 at 9:15 a.m., the Director of Nursing (DON) was asked if LPN #2 and CNA #2, who were present during Resident #16's fall on 8/1/13, were scheduled to work any of the rest of the week for interview. She stated, "No, they have been terminated. I don't think they would answer their phone or even talk to you, since their termination, even though their termination had nothing to do with this incident." She was then asked if the staff should have known to transfer the bed alarm from the resident's bed to her chair, since she had had increased confusion, lethargy, had been medicated with pain medications times 2 and antianxiety medication, along with multiple attempts to get up without assistance during the 8-hour period after her admission. She stated, "Yes, probably so."

Complaint # was substantiated (all or in part) in these findings. Based on record review and interview, the facility failed to ensure Resident #4 was free from abuse. The facility failed to ensure staff were trained and competent in recognizing signs and symptoms of burn out, reporting procedures and in the development and consistent implementation of interventions to prevent possible abuse for 1 (Residents #4) of 6 (Residents #1 through 6) case mix residents who resided on the 300, 400, 500, and 600 halls where Certified Nurses Assistants (CNAs) # 1, 2, and 5 worked in the facility. The facility failed to fully investigate staff statements obtained during the investigation of verbal and physical abuse to ensure appropriate actions were taken to protect residents from the potential of further abuse for 1 (Residents #4) of 6 (Residents #1 through 6) case mix residents who resided on the 300, 400, 500, and 600 halls where Certified Nurses Assistants (CNAs) # 1, 2, and 5 worked in the facility. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #4 who was verbally and physically abused by CNA #5 and had the potential to affect 71 residents who were cognitively impaired and required assistance with activities of daily living (total census: 119), as documented on a Room Bed List dated 2/26/13. The facility was informed of the Immediate Jeopardy condition on 2/14/13 at 4:05 p.m. The findings are: 1. The facility's policy titled "Abuse Investigation (and) Reporting Policy" documented "... II. Staff Training and Competency. 1. New employee orientation. At new employee orientation, all employees will be given a copy of the Facility's Abuse Policy ... 2. Inservices. a. The Facility will conduct in-service programs at least annually for all employees reviewing the Facility's Policy and the proper procedures for protecting patients and reporting suspected or alleged abuse or neglect of patients. Attendance at in-service training programs is mandatory, and attendance will be taken and recorded. b. In-service programs may include the following information: ... ix. Stress reduction and burn-out, including how staff should intervene if other staff lose control or abuse a patient ... III. Identifying, Investigating, (and) Reporting ... 4. Identification and investigation. ... b. Interviews. Identification and investigation of abuse, neglect, or misappropriation of property should include interviews with those persons the investigator determines are related to allegation or incident. The investigator should consider interviewing persons listed below: i. Facility employees ... ii. Victim patient; iii. Patient's room mate; iv. Other patients ..." 2. Resident #4 had a [DIAGNOSES REDACTED]. a. The Office of Long Term Care (OLTC) Incident and Accident Report (I & (and) A) DMS-7734 documented "Date and Time Submitted (if known): 12/28/12 11:00 a.m. Date & Time of Discovery: 12/28/12 1:15 a.m. ... Date of I & A: 12/28/12. Time: 1:15 a.m. Name of Resident (Resident #4) ... Status of Alleged Perpetrator: Facility Employee ... Type of Incident: ... Abuse: Verbal ... Physical ... Summary of Incident: On December 28, 2012 nurse (Licensed Practical Nurse (LPN) #2) heard yelling, she went down 600 hall and found CNA (Certified Nursing Assistant (CNA) #5) yelling at resident. Aide was leaning over resident, grabbing both of his wrist, holding them against his chest and yelling, "Quit this [***] ing[***] I have to do my job." Nurse immediately intervened and removed aide from room. Nurse immediately suspended aide and removed him from facility... Steps Taken to Prevent Continued Abuse or Neglect During the Investigation: ... Administrator, Director of Nursing and Officer (name) interviewed resident on December 28. 2012 at 9:15 a.m. Resident reported that aide was trying to 'beat me up', he didn't hear the aide say anything to him because he didn't have his hearing aide in. Resident stated he was ok and did not have bruises around his wrist. He did not want to file charges against aide, he stated he hadn't had any problems with aide before. Body audit completed by treatment nurse with new findings of fresh scratch marks on left upper arm time three and area is red and raised. Marks consistent with fingernail marks. Facility is interviewing staff members who have worked with aide to determine if they witnessed any of these events. Facility is also interviewing residents who aide worked with to determine if there were any additional events that may have occurred. Facility is inservicing staff regarding abuse and neglect policy and procedure with emphasis on what to do if someone identifies abuse, protecting resident and identifying staff members that are having a change in demeanor or behavior to prevent abuse/neglect before it occurs. Employee suspended beginning on December 28, 2012 around 1:30 a.m., employees employment will be terminated based on the information obtained, however investigation will continue to complete additional interviews, in-services and monitoring of resident." b. The OLTC Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, & Exploitation of Resident in Long Term Care Facilities form DMS-762 documented, "...Date and Time of Incident (if known): 12/28/12. Time: 1:15 a.m. ... Type of Incident: ... Abuse: Verbal ... Physical ... Name of Involved Resident: (Resident #4) ... Physical Functional Level/Impairment: Resident requires assistance for all ADLs (Activities of Daily Living), Resident had left sided paralysis ... Section II - Complete Description of Incident ... On December 28, 2012 nurse (LPN #2) heard yelling, she went down 600 hall and found CNA (CNA #5) yelling at resident. Aide was leaning over resident, grabbing both of his wrist, holding them against his chest and yelling, "Quit this [***] ing[***] I have to do my job." Nurse immediately intervened and removed aide from room. Nurse immediately suspended aide and removed him from facility. Section III - Findings and Actions Taken ... Interview with resident revealed that resident did not have his hearing aides in on the morning of the incident. He did not hear what aide was telling him, he thought that the aide (was) trying to 'beat him' up and didn't know why. He said he had not had any problems with this aide before and wasn't sure why he was trying to 'beat him up'. Interview with (CNA #5) via telephone: aide did admit to yelling (at) resident and (grabbing) him, but said that resident was being resistant to care. Aide stated that he was trying to protect himself. Aide was informed that his employment had been terminated due to incident. Interview with nurse (LPN #2) confirms that she walked in on the event. She witnessed aide cursing and yelling at resident as well as him grabbing the resident. Interviews with cognitive residents did not reveal any other incidents involving this aide. Interviews with staff members did not reveal any incidents of abuse with this aide. Based on the above information facility supports the allegation of abuse and has terminated aide." The form was signed by the Administrator on 1/4/13. c. The OLTC Witness Statement Form signed by (CNA #1) documented, "Date: 12/18/12. Time: 1:15 a.m. ... Job Title: CNA. Shift 11:00 p.m. to 7:00 a.m. ... State in your own words what you witnessed (be very descriptive) and sign below: I have worked with (CNA #5) on halls before. I've seen him get impatient with residents and start to be a little rough and yell at the residents. I've seen him restrain (resident) (Resident #6) but only when (resident) was trying to punch myself or (CNA #5)... He has never hit a resident and he's good with resident, sometimes he just gets agitated." 1) The OLTC Witness Statement Form signed by (CNA #1) documented, "Date: 2/13/12. Time: 10:50 p.m... Job Title: CNA. Shift 11:00 p.m. to 7:00 a.m... State in your own words what you witnessed (be very descriptive) and sign below: To clarify 12/28/12 statement. When I said yelling I (meant) he was talking loud. I have never heard him yell cuss words at a resident. When I said little rough, moved residents fast or quickly but he never hurt anyone body." 2) On 2/14/13 at 7:12 a.m., CNA #1 was asked, "Do you have any concerns regarding abuse or neglect occurring in the facility?" CNA #3 stated, "I've seen one guy, (CNA #5). If a resident was combative he'd hold a resident down while the other aide, which was usually me, would change them." CNA #1 demonstrated the resident's arms would be crossed over the resident's chest and one hand of the aide would be placed over the crossed wrist area. CNA #1 was asked, "How often did this happen?" CNA #1 stated, "Mostly with (Resident # 6), maybe 3 times back when he first got here. Then we figured out he was combative with males only." CNA #1 was asked, "Did you think this was okay?" CNA #1 stated, "I didn't think it was okay to hold the resident, but the resident didn't complain and he (CNA #5) was gentle with holding him (Resident #6) and it kept us from getting hit or the resident from hitting his arms on the bed." CNA #1 was asked, "Did you tell anyone?" CNA #1 stated, "No, he never did anything that was abuse." CNA #1 was asked, "What are some signs of burn out or stress?" CNA #1 stated, "Yelling, cussing, tell you I don't want to be here, I don't like this job." CNA #1 was asked, "Have you seen any staff members with burnout?" CNA #1 stated, "Not since (CNA #5), no." CNA #1 was asked, "What did you do?" CNA #1 stated, "Usually I'd tell (CNA #5) to go take care of another resident so (CNA #5) didn't have to do it." CNA #1 was asked, "Did you ever hear (CNA #5) cuss residents?" CNA #1 stated, "He would cuss under his breath and when the resident would say 'What?' (CNA #5) would say 'Nothing'." CNA #1 was asked, "He did this in the presence of residents?" CNA #1 stated, "Yes." CNA #1 was asked, "Which resident?" CNA #1 stated "Which ever one was upsetting him." CNA #1 was asked, "What did you do about that?" CNA #1 stated, "I told (CNA #5) to go ahead and go I've got this resident and I told (LPN #2), our nurse and after I told her she told him, 'You can't be doing that around residents.' After that he wouldn't get residents up with me. He'd give me certain residents and he'd do the others." CNA #1 was asked, "Did you ever see (CNA #5) get impatient or rough with residents?" CNA #1 stated, "I would see him move residents up by himself, without asking for help kind of rough and I'd see him transfer residents up to the chair by himself who were a 2 person and I'd offer to help. He'd do it quicker than I liked and he'd say 'No, just hold the wheelchair'." CNA #1 was asked, "Did any resident get hurt or complain about him being rough?" CNA #1 stated, "No." CNA #1 was asked, "Did you ever see (CNA #5) restrain a resident?" CNA #1 stated "When they were being combative, he'd hold their wrist up to their chest." CNA #1 was asked, "Is it okay to hold a resident's wrist to restrain them?" CNA #1 stated, "I had thought before it was okay but I've now been told it is not." CNA #1 was asked, "Your statement dated 12/28/12, 'little rough' means what?" CNA #1 stated, "Transferring really quickly and the restraining residents by their wrist." CNA #1 was asked "What is agitated in your statement?" CNA #1 stated, "He'd restrain them more, he'd tell the resident we have to do this and come on now." CNA #1 was asked, "After you wrote the statement, did anyone talk with you?" CNA #1 stated, "Yes, (Director of Nurses (DON)) and (Administrator) called me yesterday (2/14/13) about this." CNA #1 was asked, "What did they say?" CNA #1 stated, "They questioned what the witness statement I wrote meant. What did the rough mean. I told them the holding wrist to chest, restraining them, pulling them up in bed, moving them from bed to wheelchair faster." CNA #1 was asked, "Did they say anything else?" CNA #1 stated, "They asked me to come in and write another statement." CNA #1 was asked, "Was any counseling or warning done with you?" CNA #1 stated, "No." 3) On 2/14/13 at 10:00 a.m. this Surveyor requested the employee file and disciplinary counselings for CNA #1. 4) On 2/14/12 at 12:10 p.m. the employee file for CNA #1 was reviewed. The Employee Disciplinary Action form for CNA #1 documented, "Date of Occurrence: 2/14/13. Date of Counseling: 2/14/13. Type of Action: Verbal ... Description of Occurrence: Failure to report allegations of abuse or neglect... Corrective Action Taken: Re-inservice on abuse and neglect... Spoke with aide via telephone on 2/13/13 regarding reporting anything that she felt could possibly be considered abuse. Gave aide formal write up on 2/14/13." The back side of the Employee Disciplinary Action form documented, "Spoke with CNA in December regarding her statement made regarding (CNA #5). Received clarification about her meaning of 'rough' and 'yelling'. At that time discussed with aide the importance of reporting any behaviors or issues that could be possibly considered abuse or neglect." The form was signed by the Administrator with date of 12/28/12 documented. d. The OLTC Witness Statement Form signed by (CNA #2) documented, "Date: 12/18/12. Time: (Blank) ... Job Title: CNA. Shift 11:00 p.m. to 7:00 a.m. ... State in your own words what you witnessed (be very descriptive) and sign below: I have worked with (CNA #5) before. I've seen him start to get agitated with residents but never let it escalate to more. If I notice he's getting worked up I have him leave the room or I try to talk to resident..." 1) On 2/14/13 at 7:55 a.m. CNA #2 was asked, "What are some of the signs of staff burn out or stress?" CNA #2 stated, "They don't care as much, just in and out." CNA #2 was asked "Have you seen any staff members with burn out?" CNA #2 stated, "No." CNA #2 was asked, "Did you ever work with (CNA #5)?" CNA #2 stated, "Yes." CNA #2 was asked "Did you ever see (CNA #5) get impatient or rough with residents?" CNA #2 stated, "Any time I saw him get impatient, I'd tell him to leave..." CNA #2 was asked, "What do you mean by impatient?" CNA #2 stated, "(CNA #5's) facial expressions would change, he'd get upset." CNA #2 was asked, "Your statement dated 12/28/12, who 'never let it escalate'?" CNA #2 stated, "I never let it escalate." CNA #2 was asked, "Did you talk with any one about (CNA #5)?" CNA #2 stated, "No, he never really did anything. I'd either send (CNA #5) out or talk to the resident and distract them and (CNA #5) would be okay." CNA #2 was asked, "How often did you tell him to leave?" CNA #2 stated, "I only worked with him for about a month?" CNA #2 was asked, "How many times did you tell him to leave?" CNA #2 stated, "Maybe twice. I'd tell (CNA #5) to leave or I'd tell (CNA # 5) I'd do the resident from now on. You have to understand that it was only with (Resident #6)." 2) On 2/14/13 at 10:00 a.m., this surveyor requested the employee file and disciplinary counselings for CNA #2. 3) On 2/14/12 at 12:10 p.m. the employee file for CNA # 2 was reviewed. There were no documented disciplinary counselings or inservices in this employee's file. e. The OLTC Witness Statement Form signed by LPN #2 documented, "Date: 12/18/12. Time: 1:15 a.m. ... Job Title: LPN. Shift Night (11:00 p.m. to 7:00 a.m.) ... State in your own words what you witnessed (be very descriptive) and sign below: I was sitting (at) nurse's station, heard CNA yelling, went down hall (and) found CNA in (Resident #4's) room. CNA was leaning over resident, grabbing both of (resident's) wrist, holding them against his chest (and) yelling (at) (resident). Overheard CNA telling (resident) to 'Quit this [***] ing[***] I have to do my job.' I intervened (and) had CNA let go of (resident), before CNA could back away, (resident) grabbed CNA's scrub top and tried to pull him closer, obviously upset. Asked CNA to leave room (and) clocked out about 1:30 a.m." On 2/14/13 at 7:42 a.m. LPN #2 was asked, "What are some of the signs of staff burnout?" LPN #2 stated, "Personality change, short temper, snappy." LPN #2 was asked, "When you see signs of burn out what do you do?" LPN #2 stated, "I send them out for a breather, get another CNA to help or I go help while the other CNA is gone. If it's excessive and a break doesn't help, I have them talk with CNA supervisor (Lead CNA) and I talk with CNA supervisor." LPN #2 was asked, "Do you tell the DON (Director of Nursing) or Administrator?" LPN #2 stated "If it's excessive, yes." LPN #2 was asked, "Have you ever heard a CNA yell at a resident?" LPN #2 stated, "I have once." LPN #2 was asked, "Who?" LPN #2 stated "(CNA #5), he no longer works here." LPN #2 was asked, "What did you do?" LPN #2 stated, "I sent him home that night." LPN #2 was asked, "Ever see (CNA #5) get impatient or rough with a resident?" LPN #2 stated, "Not before this incident. He wasn't on my hall and I didn't work with him a lot." LPN #2 was asked, "Who was his LPN mostly?" LPN #2 stated, "(LPN #1), she's 3:00 p.m. to 11:00 p.m. now." LPN #2 was asked, "Did any CNAs report concerns with (CNA #5) before this incident?" LPN #2 stated, "No, not that I remember." LPN #2 was asked, "Did you ever hear CNAs telling (CNA #5) to go and take a break when he looked stressed?" LPN #2 stated, "No." f. There were no other 11:00 p.m. to 7:00 a.m. staff interviews or resident interviews documented. g. On 2/11/13 at 12:45 p.m. the Inservice Education Report that was part of this abuse allegation investigation received from the Administrator was copied. The Inservice Education Report dated 12/18/12 documented, "... Topics: Abuse and Neglect: See attached handout. 7 types of abuse: physical, mental, verbal, sexual, involuntary seclusion, misappropriation of property and neglect. Identifying - If you witness abuse you must report immediately; Anyone who sees or hears abuse must report immediately. In order to protect residents that are possible victims of abuse the alleged staff member is suspended immediately and if the alleged perpetrator is not identified then the resident will receive care in pairs." There were no signatures of any staff members on the sign in sheet. The attached handout did not include signs/symptoms of burn out and who to report possible burnout to. On 2/11/13 at 12:45 p.m. a second Inservice Education Report that was part of this abuse allegation investigation received from the Administrator was copied. The Inservice Education Report dated 12/18/12 documented, "... Topics: Abuse and Neglect: See attached handout. 7 types of abuse: physical, mental, verbal, sexual, involuntary seclusion, misappropriation of property and neglect. Identifying - If you witness abuse you must report immediately; Anyone who sees or hears abuse must report immediately. In order to protect residents that are possible victims of abuse the alleged staff member is suspended immediately and if the alleged perpetrator is not identified then the resident will receive care in pairs." There was one signature on the sign in sheet, which was not CNA #1 or 2. The attached handout did not include signs/symptoms of burn out and who to report possible burnout to. h. On 2/13/13 at 1:50 p.m., the Administrator was asked for inservices on abuse/neglect done since 12/1/12. On 2/13/12 at 3:00 p.m. an Inservice Education Report was received from the Administrator and was copied. The Inservice Education Report dated 12/18/12 documented "... Topics: Abuse and Neglect: See attached handout. 7 types of abuse: physical, mental, verbal, sexual, involuntary seclusion, misappropriation of property and neglect. Identifying - If you witness abuse you must report immediately; Anyone who sees or hears abuse must report immediately. In order to protect residents that are possible victims of abuse the alleged staff member is suspended immediately and if the alleged perpetrator is not identified then the resident will receive care in pairs." There were seventeen signatures on the sign in sheet, which did not include CNA #1 or 2. The attached handout did not include signs/symptoms of burn out and who to report possible burnout to. On 2/13/12 at 3:00 p.m. a second Inservice Education Report was received from the Administrator and was copied. The Inservice Education Report dated 1/3/13 documented "... Topics: Dress Code: ... Abuse and Neglect and Misappropriation of property. 1. If you know of any type of abuse, neglect or stolen property report it immediately to supervisor. 2. Always protect resident. 3. Keep aware of any changes in resident because this could be a result of possible abuse. 4. Communicate with each other and residents regarding any changes in residents." There were 64 signatures on the sign in sheet, which did not include CNA #1 or 2. The inservice did not include signs/symptoms of burn out and who to report possible burnout to. i. On 2/13/13 at 3:20 p.m. LPN #1 stated she had worked in the facility since August 2012 on the 400, 500, and 600 halls. LPN #1 stated she had been working on the 3:00 p.m. to 11:00 p.m. shift since 12/15/12. LPN #1 stated prior to this she worked the 11:00 p.m. to 7:00 a.m. shift. LPN #1 was asked, "What are the signs of possible burn out that you might see from staff members?" LPN #1 stated, "Frazzled, look stressed, tone of voice sharp, harsh." LPN #1 was asked, "Did you ever work with (CNA #5)?" LPN #1 stated, "Yes a few times". LPN #1 was asked, "How long ago?" LPN #1 stated, "Sometime before the middle of December." LPN #1 was asked, "Did you ever hear (CNA #5) yell at residents?" LPN #1 stated, "I didn't hear him yell. He was an older man, his tone sometimes came across as aggressive. We had addressed it before with him." LPN #1 was asked, "Addressed it?" LPN #1 stated, "You could hear it in his voice when he got overwhelmed and we'd say 'It's okay (CNA #5), we'll get you some help, we'll get through it." LPN #1 was asked, "What do you mean by aggressive tone?" LPN #1 stated, "Not patient, louder." LPN #1 was asked, "Did that happen often?" LPN #1 stated, "Not often." LPN #1 was asked, "How frequently did it happen?" LPN #1 stated, "I addressed it with him twice in the few months I worked with him." LPN #1 was asked, "Did you report his behavior to any one else?" LPN #1 stated, "Yes, to the lead CNA. We passed it on that he had gotten frazzled." LPN #1 was asked, "Is that the chain of command with CNAs, that you report problems to the lead CNAs?" LPN #1 stated, "Yes and if I don't think the problem is being addressed I mention it to my DON." LPN #1 was asked, "Who is the lead CNA you talked with?" LPN #1 stated "(Lead CNA #1) and (Lead CNA #2)." LPN #1 was asked, "Did you talk with the DON regarding (CNA #5)?" LPN #1 stated, "No." j. On 2/14/13 at 8:17 a.m., CNA #3, who worked the 11:00 p.m. to 7:00 a.m. shift, on the 400, 500, and 600 halls, was asked, "Did you ever work with (CNA #5)?" CNA #3 stated "Yes." CNA #5 was asked, "Did you ever hear (CNA #5) cuss a resident?" CNA #3 stated, "No." CNA #3 was asked, "Did you ever hear him cuss under his breath when taking care of a resident?" CNA #5 stated, "Yes, I heard him say 'Damn it' once when he was done with a resident. I only worked with him a few times, maybe three, he never cussed at a resident, it was more like 'Holy[***]this job sucks'." CNA #3 was asked, "Did you tell anyone?" CNA #3 stated, "No." k. On 2/14/13 at 10:22 a.m., CNA #4 was asked, "What are some of the signs of staff burn out or stress?" CNA #4 stated, "Not as fast with care, more smoke breaks, facial expressions change, body language tense." CNA #4 was asked, "What would you do if you noticed signs of burn out/stress?" CNA #4 stated, "Ask the person if they are okay, tell the Lead CNA." l. On 2/14/13 at 10:35 a.m. Lead CNA #1 was asked, "What are some of the signs of staff burn out or stress?" Lead CNA #1 stated, "Walk the halls, don't want to be here, complain too much." Lead CNA #1 was asked, "Have you seen any staff members with burn out?" CNA #1 stated, "Yes, a second shift (3:00 p.m. to 11:00 p.m.) CNA was complaining so much that I asked if she was okay. She said she was. I think her frustration was with the new NA (Nurses Assistant)." Lead CNA #1 was asked, "For burn out or stress what do you do?" Lead CNA #1 stated, "Talk with the CNA and report to the DON." Lead CNA #1 was asked, "Did the night shift staff, CNAs or LPNs, come to you with concerns regarding (CNA #5)?" Lead CNA #1 stated, "No." m. On 2/14/13 at 10:43 a.m. Lead CNA #2 was asked, "What are some of the signs of staff burn out or stress?" Lead CNA #2 stated, "Facial expression, body language, and attitude change." Lead CNA #2 was asked, "Have you seen any staff members with burn out?" Lead CNA #2 stated, "No, nothing major." Lead CNA #2 was asked, "What did you do?" Lead CNA #2 stated, "If I think they may have burn out, I ask them. I offer to move them from the hall they are on, ask if they need a break. I tell the DON when I notice burn out." Lead CNA #2 was asked, "Did any of the night shift CNAs ever report concerns about (CNA #5)?" Lead CNA #2 stated, "No." Lead CNA #2 was asked, "Did any night shift LPNs report concerns with (CNA #5)?" Lead CNA #2 stated "No." n. On 2/14/13 at 10:57 a.m. LPN #3 stated she worked the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shifts on the 400, 500, and 600 halls. LPN #3 was asked, "What are some of the signs of burn out?" LPN #3 stated, "Irritability, lack of attention to residents, don't spend time with residents, frequent breaks, a lack of quality in their work." LPN #3 was asked, "What do you do when you see signs of burn out?" LPN #3 stated, "Talk to them, if working too many hours tell the Lead CNA to cut back on hours and give them time off." o. On 2/14/13 at 1:50 p.m. the Administrator was asked to review the investigation for Resident #4. The Administrator was asked, "You got statements from how many CNAs and LPNs?" The Administrator stated, "(CNA #1), (CNA #2), and (LPN #2)." The Administrator was asked, "Did you do any resident interviews?" The Administrator stated, "We have body audits my treatment nurse did that day." The Administrator was asked, "Are there interviews from other residents?" The Administrator stated, "We did them. I don't know why they aren't in here." The Administrator was asked, "What did you do when you read (CNA #1's) statement?" The Administrator stated, "We called her and clarified rough as he was moving him quickly. I should have had her write another statement and this a.m. we did a verbal write up. We looked at this again yesterday when you said you needed this back today." The Administrator was asked, "We?" The Administrator stated, "(DON) and me." The Administrator was asked, "Do you know of anyone talking to (CNA #5) prior to 12/28/12 about his tone, etc.?" The Administrator stated, "I'll have to look." As of 2/15/13 at 12:30 p.m., the Administrator had not provided any counselings for CNA #5 other than the termination done on 12/28/12. The Administrator was asked, "On the inservice dated 1/3/13, did you cover signs/symptoms of burn out?" The Administrator stated, "It's not written down but I usually cover it." The Administrator was asked, "Was (CNA #1) in-serviced after this on the 1/3/13 or 12/28/13 inservices on abuse or neglect?" The Administrator stated "No." The Administrator was asked, "Was (CNA #2) inserviced on abuse or neglect after statement?" The Administrator stated, "No." p. On 2/14/13 at 2:35 p.m. the Social Service Director was asked, "Did you do any resident interviews regarding staff cussing, yelling or rough treatment, etc. after this happened on 12/28/12?" The Social Service Director stated, "No." q. On 2/14/13 at 2:40 p.m. the DON was asked, "Did you see (CNA #1's) or (CNA #2's) statements before yesterday?" The DON stated, "I can't tell you with 100% accuracy if I did or not. Not up until yesterday and I know I reviewed them then." The DON was asked "What does (CNA #1's) statement say to you?" The DON stated, "There's a history and she's not reporting abuse and neglect." The DON was asked, "Did you talk with (CNA #1) before yesterday about her statement?" The DON stated, "I don't recall." The DON was asked, "What about (CNA #2's) statement?" The DON stated, "There's a problem there too." The DON was asked, "Did (LPN #1) talk to you about (CNA #5) being 'aggressive' before this happened on 12/28/12?" The DON stated, "Never." 3. The Immediate Jeopardy was removed and the scope/severity reduced to "E" on 2/14/13 when the facility implemented the following Plan of Removal: a. Identification: 1. Residents at risk for this failed practice include 24 residents on 300 hall, 26 residents on 400 hall, 19 residents on 500 hall and 18 residents on 600 hall. b. Assessments: 1. All residents in facility were assessed for any skin issues that might be indicative of abuse or neglect beginning at 3:00 p.m. on 2/14/13 and completed on 2/14/13. There were no issues noted on these skin assessments. 2. All cognitive residents in facility were interviewed to determine if they have been abused or neglected on 2/14/13 beginning at 3:00 p.m. and completed on 2/14/13, no issues were reported. c. Training: 1. All nursing staff in-serviced at the beginning of each shift, beginning on 2/14/13 at 3:00 p.m. and will be ongoing to include new hires and staff returning from leave. Training will take place before staff work on floor. Training will be done by DON/designee and in-service sign-in sheets used. Training will include verbal training on abuse, neglect, reporting and identification of staff burn out and if staff see another staff member with these signs to report it immediately to their direct supervisor and/or DON/designee. 2. Administrator has been in-serviced by Nursing Consultant regarding completion of a thorough abuse investigation on 2/14/13 at 3:00 p.m. d. Monitor: 1. Director of Nursing/designee will monitor body audits weekly beginning 2/14/13 to identify any issues that could be indicative of abuse or neglect, if any issue noted it will be addressed immediately. 2. Director of Nursing/designee will monitor incident and accident reports daily to (identify) any incident that could be the result of abuse, neglect (and/or) staff burn out beginning 2/14/13 and address any issue immediately. 3. Administrator/designee will interview 2 staff members on day shift, 2 staff members on evening (shift) and 2 staff members on night shift daily beginning on 2/15/13 to discuss if they have seen any staff members with signs of staff burnout or if they have staff burn out, any issue will be addressed immediately.

Complaint # was substantiated (all or in part) in these findings. Based on record review, and interview the facility failed to ensure signs and symptoms of burn out were reported and interventions developed and consistently implemented to prevent possible abuse and failed to fully investigate staff statements obtained during the investigation of verbal and physical abuse to ensure appropriate actions were taken to protect residents from the potential of further abuse for 1 (Residents #4) of 6 (Residents #1 through 6) case mix residents who resided on the 300, 400, 500, and 600 halls where Certified Nurses Assistants (CNAs) #1, 2, and 5 worked. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #4 who was verbally and physically abused by CNA #5 and had the potential to affect 71 residents who were cognitively impaired and required assistance with activities of daily living (total census: 119), as documented on a Room Bed List dated 2/26/13. The facility was informed of the Immediate Jeopardy condition on 2/14/13 at 4:05 p.m. The facility also failed to thoroughly investigate an allegation of neglect, verbal and physical abuse on the 200 hall for 1 of 1 (Resident #7) case mix resident who alleged abuse and to thoroughly investigate an allegation of misappropriation of personal property on the 100 hall for 1 of 1 (Resident #8) case mix resident who made an allegation of misappropriation of property. These failed practices had the potential to cause more than minimal harm for 33 residents who resided on 2 of 6 halls, as documented on lists provided by the Assistant Administrator on 2/15/13. The findings are: 1. Resident #4 had a [DIAGNOSES REDACTED]. a. The Office of Long Term Care (OLTC) Incident and Accident Report (I & (and) A) DMS-7734 documented "Date and Time Submitted (if known): 12/28/12 11:00 a.m. Date & Time of Discovery: 12/28/12 1:15 a.m. ... Date of I & A: 12/28/12. Time: 1:15 a.m. Name of Resident (Resident #4) ... Status of Alleged Perpetrator: Facility Employee ... Type of Incident: ... Abuse: Verbal ... Physical ... Summary of Incident: On December 28, 2012 nurse (Licensed Practical Nurse (LPN) #2) heard yelling, she went down 600 hall and found CNA (Certified Nursing Assistant (CNA) #5) yelling at resident. Aide was leaning over resident, grabbing both of his wrist, holding them against his chest and yelling, "Quit this [***] ing[***] I have to do my job." Nurse immediately intervened and removed aide from room. Nurse immediately suspended aide and removed him from facility... Steps Taken to Prevent Continued Abuse or Neglect During the Investigation: ... Administrator, Director of Nursing and Officer (name) interviewed resident on December 28. 2012 at 9:15 a.m. Resident reported that aide was trying to 'beat me up', he didn't hear the aide say anything to him because he didn't have his hearing aide in. Resident stated he was ok and did not have bruises around his wrist. He did not want to file charges against aide, he stated he hadn't had any problems with aide before. Body audit completed by treatment nurse with new findings of fresh scratch marks on left upper arm time three and area is red and raised. Marks consistent with fingernail marks. Facility is interviewing staff members who have worked with aide to determine if they witnessed any of these events. Facility is also interviewing residents who aide worked with to determine if there were any additional events that may have occurred. Facility is inservicing staff regarding abuse and neglect policy and procedure with emphasis on what to do if someone identifies abuse, protecting resident and identifying staff members that are having a change in demeanor or behavior to prevent abuse/neglect before it occurs. Employee suspended beginning on December 28, 2012 around 1:30 a.m., employees employment will be terminated based on the information obtained, however investigation will continue to complete additional interviews, in-services and monitoring of resident." b. The OLTC Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, & Exploitation of Resident in Long Term Care Facilities form DMS-762 documented, "...Date and Time of Incident (if known): 12/28/12. Time: 1:15 a.m. ... Type of Incident: ... Abuse: Verbal ... Physical ... Name of Involved Resident: (Resident #4) ... Physical Functional Level/Impairment: Resident requires assistance for all ADLs (Activities of Daily Living), Resident had left sided paralysis ... Section II - Complete Description of Incident ... On December 28, 2012 nurse (LPN #2) heard yelling, she went down 600 hall and found CNA (CNA #5) yelling at resident. Aide was leaning over resident, grabbing both of his wrist, holding them against his chest and yelling, "Quit this [***] ing[***] I have to do my job." Nurse immediately intervened and removed aide from room. Nurse immediately suspended aide and removed him from facility. Section III - Findings and Actions Taken ... Interview with resident revealed that resident did not have his hearing aides in on the morning of the incident. He did not hear what aide was telling him, he thought that the aide (was) trying to 'beat him' up and didn't know why. He said he had not had any problems with this aide before and wasn't sure why he was trying to 'beat him up'. Interview with (CNA #5) via telephone: aide did admit to yelling (at) resident and (grabbing) him, but said that resident was being resistant to care. Aide stated that he was trying to protect himself. Aide was informed that his employment had been terminated due to incident. Interview with nurse (LPN #2) confirms that she walked in on the event. She witnessed aide cursing and yelling at resident as well as him grabbing the resident. Interviews with cognitive residents did not reveal any other incidents involving this aide. Interviews with staff members did not reveal any incidents of abuse with this aide. Based on the above information facility supports the allegation of abuse and has terminated aide." The form was signed by the Administrator on 1/4/13. c. The OLTC Witness Statement Form signed by (CNA #1) documented, "Date: 12/18/12. Time: 1:15 a.m. ... Job Title: CNA. Shift 11:00 p.m. to 7:00 a.m. ... State in your own words what you witnessed (be very descriptive) and sign below: I have worked with (CNA #5) on halls before. I've seen him get impatient with residents and start to be a little rough and yell at the residents. I've seen him restrain (resident) (Resident #6) but only when (resident) was trying to punch myself or (CNA #5)... He has never hit a resident and he's good with resident, sometimes he just gets agitated." 1) The OLTC Witness Statement Form signed by (CNA #1) documented, "Date: 2/13/12. Time: 10:50 p.m... Job Title: CNA. Shift 11:00 p.m. to 7:00 a.m... State in your own words what you witnessed (be very descriptive) and sign below: To clarify 12/28/12 statement. When I said yelling I (meant) he was talking loud. I have never heard him yell cuss words at a resident. When I said little rough, moved residents fast or quickly but he never hurt anyone body." 2) On 2/14/13 at 7:12 a.m., CNA #1 was asked, "Do you have any concerns regarding abuse or neglect occurring in the facility?" CNA #3 stated, "I've seen one guy, (CNA #5). If a resident was combative he'd hold a resident down while the other aide, which was usually me, would change them." CNA #1 demonstrated the resident's arms would be crossed over the resident's chest and one hand of the aide would be placed over the crossed wrist area. CNA #1 was asked, "How often did this happen?" CNA #1 stated, "Mostly with (Resident # 6), maybe 3 times back when he first got here. Then we figured out he was combative with males only." CNA #1 was asked, "Did you think this was okay?" CNA #1 stated, "I didn't think it was okay to hold the resident, but the resident didn't complain and he (CNA #5) was gentle with holding him (Resident #6) and it kept us from getting hit or the resident from hitting his arms on the bed." CNA #1 was asked, "Did you tell anyone?" CNA #1 stated, "No, he never did anything that was abuse." CNA #1 was asked, "What are some signs of burn out or stress?" CNA #1 stated, "Yelling, cussing, tell you I don't want to be here, I don't like this job." CNA #1 was asked, "Have you seen any staff members with burnout?" CNA #1 stated, "Not since (CNA #5), no." CNA #1 was asked, "What did you do?" CNA #1 stated, "Usually I'd tell (CNA #5) to go take care of another resident so (CNA #5) didn't have to do it." CNA #1 was asked, "Did you ever hear (CNA #5) cuss residents?" CNA #1 stated, "He would cuss under his breath and when the resident would say 'What?' (CNA #5) would say 'Nothing'." CNA #1 was asked, "He did this in the presence of residents?" CNA #1 stated, "Yes." CNA #1 was asked, "Which resident?" CNA #1 stated "Which ever one was upsetting him." CNA #1 was asked, "What did you do about that?" CNA #1 stated, "I told (CNA #5) to go ahead and go I've got this resident and I told (LPN #2), our nurse and after I told her she told him, 'You can't be doing that around residents.' After that he wouldn't get residents up with me. He'd give me certain residents and he'd do the others." CNA #1 was asked, "Did you ever see (CNA #5) get impatient or rough with residents?" CNA #1 stated, "I would see him move residents up by himself, without asking for help kind of rough and I'd see him transfer residents up to the chair by himself who were a 2 person and I'd offer to help. He'd do it quicker than I liked and he'd say 'No, just hold the wheelchair'." CNA #1 was asked, "Did any resident get hurt or complain about him being rough?" CNA #1 stated, "No." CNA #1 was asked, "Did you ever see (CNA #5) restrain a resident?" CNA #1 stated "When they were being combative, he'd hold their wrist up to their chest." CNA #1 was asked, "Is it okay to hold a resident's wrist to restrain them?" CNA #1 stated, "I had thought before it was okay but I've now been told it is not." CNA #1 was asked, "Your statement dated 12/28/12, 'little rough' means what?" CNA #1 stated, "Transferring really quickly and the restraining residents by their wrist." CNA #1 was asked "What is agitated in your statement?" CNA #1 stated, "He'd restrain them more, he'd tell the resident we have to do this and come on now." CNA #1 was asked, "After you wrote the statement, did anyone talk with you?" CNA #1 stated, "Yes, (Director of Nurses (DON)) and (Administrator) called me yesterday (2/14/13) about this." CNA #1 was asked, "What did they say?" CNA #1 stated, "They questioned what the witness statement I wrote meant. What did the rough mean. I told them the holding wrist to chest, restraining them, pulling them up in bed, moving them from bed to wheelchair faster." CNA #1 was asked, "Did they say anything else?" CNA #1 stated, "They asked me to come in and write another statement." CNA #1 was asked, "Was any counseling or warning done with you?" CNA #1 stated, "No." 3) On 2/14/13 at 10:00 a.m. this Surveyor requested the employee file and disciplinary counselings for CNA #1. 4) On 2/14/12 at 12:10 p.m. the employee file for CNA #1 was reviewed. The Employee Disciplinary Action form for CNA #1 documented, "Date of Occurrence: 2/14/13. Date of Counseling: 2/14/13. Type of Action: Verbal ... Description of Occurrence: Failure to report allegations of abuse or neglect... Corrective Action Taken: Re-inservice on abuse and neglect... Spoke with aide via telephone on 2/13/13 regarding reporting anything that she felt could possibly be considered abuse. Gave aide formal write up on 2/14/13." The back side of the Employee Disciplinary Action form documented, "Spoke with CNA in December regarding her statement made regarding (CNA #5). Received clarification about her meaning of 'rough' and 'yelling'. At that time discussed with aide the importance of reporting any behaviors or issues that could be possibly considered abuse or neglect." The form was signed by the Administrator with date of 12/28/12 documented. d. The OLTC Witness Statement Form signed by (CNA #2) documented, "Date: 12/18/12. Time: (Blank) ... Job Title: CNA. Shift 11:00 p.m. to 7:00 a.m. ... State in your own words what you witnessed (be very descriptive) and sign below: I have worked with (CNA #5) before. I've seen him start to get agitated with residents but never let it escalate to more. If I notice he's getting worked up I have him leave the room or I try to talk to resident..." 1) On 2/14/13 at 7:55 a.m. CNA #2 was asked, "What are some of the signs of staff burn out or stress?" CNA #2 stated, "They don't care as much, just in and out." CNA #2 was asked "Have you seen any staff members with burn out?" CNA #2 stated, "No." CNA #2 was asked, "Did you ever work with (CNA #5)?" CNA #2 stated, "Yes." CNA #2 was asked "Did you ever see (CNA #5) get impatient or rough with residents?" CNA #2 stated, "Any time I saw him get impatient, I'd tell him to leave..." CNA #2 was asked, "What do you mean by impatient?" CNA #2 stated, "(CNA #5's) facial expressions would change, he'd get upset." CNA #2 was asked, "Your statement dated 12/28/12, who 'never let it escalate'?" CNA #2 stated, "I never let it escalate." CNA #2 was asked, "Did you talk with any one about (CNA #5)?" CNA #2 stated, "No, he never really did anything. I'd either send (CNA #5) out or talk to the resident and distract them and (CNA #5) would be okay." CNA #2 was asked, "How often did you tell him to leave?" CNA #2 stated, "I only worked with him for about a month?" CNA #2 was asked, "How many times did you tell him to leave?" CNA #2 stated, "Maybe twice. I'd tell (CNA #5) to leave or I'd tell (CNA # 5) I'd do the resident from now on. You have to understand that it was only with (Resident #6)." 2) On 2/14/13 at 10:00 a.m., this surveyor requested the employee file and disciplinary counselings for CNA #2. 3) On 2/14/12 at 12:10 p.m. the employee file for CNA # 2 was reviewed. There were no documented disciplinary counselings or inservices in this employee's file. e. The OLTC Witness Statement Form signed by LPN #2 documented, "Date: 12/18/12. Time: 1:15 a.m. ... Job Title: LPN. Shift Night (11:00 p.m. to 7:00 a.m.) ... State in your own words what you witnessed (be very descriptive) and sign below: I was sitting (at) nurse's station, heard CNA yelling, went down hall (and) found CNA in (Resident #4's) room. CNA was leaning over resident, grabbing both of (resident's) wrist, holding them against his chest (and) yelling (at) (resident). Overheard CNA telling (resident) to 'Quit this [***] ing[***] I have to do my job.' I intervened (and) had CNA let go of (resident), before CNA could back away, (resident) grabbed CNA's scrub top and tried to pull him closer, obviously upset. Asked CNA to leave room (and) clocked out about 1:30 a.m." On 2/14/13 at 7:42 a.m. LPN #2 was asked, "What are some of the signs of staff burnout?" LPN #2 stated, "Personality change, short temper, snappy." LPN #2 was asked, "When you see signs of burn out what do you do?" LPN #2 stated, "I send them out for a breather, get another CNA to help or I go help while the other CNA is gone. If it's excessive and a break doesn't help, I have them talk with CNA supervisor (Lead CNA) and I talk with CNA supervisor." LPN #2 was asked, "Do you tell the DON (Director of Nursing) or Administrator?" LPN #2 stated "If it's excessive, yes." LPN #2 was asked, "Have you ever heard a CNA yell at a resident?" LPN #2 stated, "I have once." LPN #2 was asked, "Who?" LPN #2 stated "(CNA #5), he no longer works here." LPN #2 was asked, "What did you do?" LPN #2 stated, "I sent him home that night." LPN #2 was asked, "Ever see (CNA #5) get impatient or rough with a resident?" LPN #2 stated, "Not before this incident. He wasn't on my hall and I didn't work with him a lot." LPN #2 was asked, "Who was his LPN mostly?" LPN #2 stated, "(LPN #1), she's 3:00 p.m. to 11:00 p.m. now." LPN #2 was asked, "Did any CNAs report concerns with (CNA #5) before this incident?" LPN #2 stated, "No, not that I remember." LPN #2 was asked, "Did you ever hear CNAs telling (CNA #5) to go and take a break when he looked stressed?" LPN #2 stated, "No." f. There were no other 11:00 p.m. to 7:00 a.m. staff interviews or resident interviews documented. g. On 2/11/13 at 12:45 p.m. the Inservice Education Report that was part of this abuse allegation investigation received from the Administrator was copied. The Inservice Education Report dated 12/18/12 documented, "... Topics: Abuse and Neglect: See attached handout. 7 types of abuse: physical, mental, verbal, sexual, involuntary seclusion, misappropriation of property and neglect. Identifying - If you witness abuse you must report immediately; Anyone who sees or hears abuse must report immediately. In order to protect residents that are possible victims of abuse the alleged staff member is suspended immediately and if the alleged perpetrator is not identified then the resident will receive care in pairs." There were no signatures of any staff members on the sign in sheet. The attached handout did not include signs/symptoms of burn out and who to report possible burnout to. On 2/11/13 at 12:45 p.m. a second Inservice Education Report that was part of this abuse allegation investigation received from the Administrator was copied. The Inservice Education Report dated 12/18/12 documented, "... Topics: Abuse and Neglect: See attached handout. 7 types of abuse: physical, mental, verbal, sexual, involuntary seclusion, misappropriation of property and neglect. Identifying - If you witness abuse you must report immediately; Anyone who sees or hears abuse must report immediately. In order to protect residents that are possible victims of abuse the alleged staff member is suspended immediately and if the alleged perpetrator is not identified then the resident will receive care in pairs." There was one signature on the sign in sheet, which was not CNA #1 or 2. The attached handout did not include signs/symptoms of burn out and who to report possible burnout to. h. On 2/13/13 at 1:50 p.m., the Administrator was asked for inservices on abuse/neglect done since 12/1/12. On 2/13/12 at 3:00 p.m. an Inservice Education Report was received from the Administrator and was copied. The Inservice Education Report dated 12/18/12 documented "... Topics: Abuse and Neglect: See attached handout. 7 types of abuse: physical, mental, verbal, sexual, involuntary seclusion, misappropriation of property and neglect. Identifying - If you witness abuse you must report immediately; Anyone who sees or hears abuse must report immediately. In order to protect residents that are possible victims of abuse the alleged staff member is suspended immediately and if the alleged perpetrator is not identified then the resident will receive care in pairs." There were seventeen signatures on the sign in sheet, which did not include CNA #1 or 2. The attached handout did not include signs/symptoms of burn out and who to report possible burnout to. On 2/13/12 at 3:00 p.m. a second Inservice Education Report was received from the Administrator and was copied. The Inservice Education Report dated 1/3/13 documented "... Topics: Dress Code: ... Abuse and Neglect and Misappropriation of property. 1. If you know of any type of abuse, neglect or stolen property report it immediately to supervisor. 2. Always protect resident. 3. Keep aware of any changes in resident because this could be a result of possible abuse. 4. Communicate with each other and residents regarding any changes in residents." There were 64 signatures on the sign in sheet, which did not include CNA #1 or 2. The inservice did not include signs/symptoms of burn out and who to report possible burnout to. i. On 2/13/13 at 3:20 p.m. LPN #1 stated she had worked in the facility since August 2012 on the 400, 500, and 600 halls. LPN #1 stated she had been working on the 3:00 p.m. to 11:00 p.m. shift since 12/15/12. LPN #1 stated prior to this she worked the 11:00 p.m. to 7:00 a.m. shift. LPN #1 was asked, "What are the signs of possible burn out that you might see from staff members?" LPN #1 stated, "Frazzled, look stressed, tone of voice sharp, harsh." LPN #1 was asked, "Did you ever work with (CNA #5)?" LPN #1 stated, "Yes a few times". LPN #1 was asked, "How long ago?" LPN #1 stated, "Sometime before the middle of December." LPN #1 was asked, "Did you ever hear (CNA #5) yell at residents?" LPN #1 stated, "I didn't hear him yell. He was an older man, his tone sometimes came across as aggressive. We had addressed it before with him." LPN #1 was asked, "Addressed it?" LPN #1 stated, "You could hear it in his voice when he got overwhelmed and we'd say 'It's okay (CNA #5), we'll get you some help, we'll get through it." LPN #1 was asked, "What do you mean by aggressive tone?" LPN #1 stated, "Not patient, louder." LPN #1 was asked, "Did that happen often?" LPN #1 stated, "Not often." LPN #1 was asked, "How frequently did it happen?" LPN #1 stated, "I addressed it with him twice in the few months I worked with him." LPN #1 was asked, "Did you report his behavior to any one else?" LPN #1 stated, "Yes, to the lead CNA. We passed it on that he had gotten frazzled." LPN #1 was asked, "Is that the chain of command with CNAs, that you report problems to the lead CNAs?" LPN #1 stated, "Yes and if I don't think the problem is being addressed I mention it to my DON." LPN #1 was asked, "Who is the lead CNA you talked with?" LPN #1 stated "(Lead CNA #1) and (Lead CNA #2)." LPN #1 was asked, "Did you talk with the DON regarding (CNA #5)?" LPN #1 stated, "No." j. On 2/14/13 at 8:17 a.m., CNA #3, who worked the 11:00 p.m. to 7:00 a.m. shift, on the 400, 500, and 600 halls, was asked, "Did you ever work with (CNA #5)?" CNA #3 stated "Yes." CNA #5 was asked, "Did you ever hear (CNA #5) cuss a resident?" CNA #3 stated, "No." CNA #3 was asked, "Did you ever hear him cuss under his breath when taking care of a resident?" CNA #5 stated, "Yes, I heard him say 'Damn it' once when he was done with a resident. I only worked with him a few times, maybe three, he never cussed at a resident, it was more like 'Holy[***]this job sucks'." CNA #3 was asked, "Did you tell anyone?" CNA #3 stated, "No." k. On 2/14/13 at 10:22 a.m., CNA #4 was asked, "What are some of the signs of staff burn out or stress?" CNA #4 stated, "Not as fast with care, more smoke breaks, facial expressions change, body language tense." CNA #4 was asked, "What would you do if you noticed signs of burn out/stress?" CNA #4 stated, "Ask the person if they are okay, tell the Lead CNA." l. On 2/14/13 at 10:35 a.m. Lead CNA #1 was asked, "What are some of the signs of staff burn out or stress?" Lead CNA #1 stated, "Walk the halls, don't want to be here, complain too much." Lead CNA #1 was asked, "Have you seen any staff members with burn out?" CNA #1 stated, "Yes, a second shift (3:00 p.m. to 11:00 p.m.) CNA was complaining so much that I asked if she was okay. She said she was. I think her frustration was with the new NA (Nurses Assistant)." Lead CNA #1 was asked, "For burn out or stress what do you do?" Lead CNA #1 stated, "Talk with the CNA and report to the DON." Lead CNA #1 was asked, "Did the night shift staff, CNAs or LPNs, come to you with concerns regarding (CNA #5)?" Lead CNA #1 stated, "No." m. On 2/14/13 at 10:43 a.m. Lead CNA #2 was asked, "What are some of the signs of staff burn out or stress?" Lead CNA #2 stated, "Facial expression, body language, and attitude change." Lead CNA #2 was asked, "Have you seen any staff members with burn out?" Lead CNA #2 stated, "No, nothing major." Lead CNA #2 was asked, "What did you do?" Lead CNA #2 stated, "If I think they may have burn out, I ask them. I offer to move them from the hall they are on, ask if they need a break. I tell the DON when I notice burn out." Lead CNA #2 was asked, "Did any of the night shift CNAs ever report concerns about (CNA #5)?" Lead CNA #2 stated, "No." Lead CNA #2 was asked, "Did any night shift LPNs report concerns with (CNA #5)?" Lead CNA #2 stated "No." n. On 2/14/13 at 10:57 a.m. LPN #3 stated she worked the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shifts on the 400, 500, and 600 halls. LPN #3 was asked, "What are some of the signs of burn out?" LPN #3 stated, "Irritability, lack of attention to residents, don't spend time with residents, frequent breaks, a lack of quality in their work." LPN #3 was asked, "What do you do when you see signs of burn out?" LPN #3 stated, "Talk to them, if working too many hours tell the Lead CNA to cut back on hours and give them time off." o. On 2/14/13 at 1:50 p.m. the Administrator was asked to review the investigation for Resident #4. The Administrator was asked, "You got statements from how many CNAs and LPNs?" The Administrator stated, "(CNA #1), (CNA #2), and (LPN #2)." The Administrator was asked, "Did you do any resident interviews?" The Administrator stated, "We have body audits my treatment nurse did that day." The Administrator was asked, "Are there interviews from other residents?" The Administrator stated, "We did them. I don't know why they aren't in here." The Administrator was asked, "What did you do when you read (CNA #1's) statement?" The Administrator stated, "We called her and clarified rough as he was moving him quickly. I should have had her write another statement and this a.m. we did a verbal write up. We looked at this again yesterday when you said you needed this back today." The Administrator was asked, "We?" The Administrator stated, "(DON) and me." The Administrator was asked, "Do you know of anyone talking to (CNA #5) prior to 12/28/12 about his tone, etc.?" The Administrator stated, "I'll have to look." As of 2/15/13 at 12:30 p.m., the Administrator had not provided any counselings for CNA #5 other than the termination done on 12/28/12. The Administrator was asked, "On the inservice dated 1/3/13, did you cover signs/symptoms of burn out?" The Administrator stated, "It's not written down but I usually cover it." The Administrator was asked, "Was (CNA #1) in-serviced after this on the 1/3/13 or 12/28/13 inservices on abuse or neglect?" The Administrator stated "No." The Administrator was asked, "Was (CNA #2) inserviced on abuse or neglect after statement?" The Administrator stated, "No." p. On 2/14/13 at 2:35 p.m. the Social Service Director was asked, "Did you do any resident interviews regarding staff cussing, yelling or rough treatment, etc. after this happened on 12/28/12?" The Social Service Director stated, "No." q. On 2/14/13 at 2:40 p.m. the DON was asked, "Did you see (CNA #1's) or (CNA #2's) statements before yesterday?" The DON stated, "I can't tell you with 100% accuracy if I did or not. Not up until yesterday and I know I reviewed them then." The DON was asked "What does (CNA #1's) statement say to you?" The DON stated, "There's a history and she's not reporting abuse and neglect." The DON was asked, "Did you talk with (CNA #1) before yesterday about her statement?" The DON stated, "I don't recall." The DON was asked, "What about (CNA #2's) statement?" The DON stated, "There's a problem there too." The DON was asked, "Did (LPN #1) talk to you about (CNA #5) being 'aggressive' before this happened on 12/28/12?" The DON stated, "Never." r. The Immediate Jeopardy was removed and the scope/severity reduced to "E" on 2/14/13 when the facility implemented the following Plan of Removal: Identification: 1. Residents at risk for this failed practice include 24 residents on 300 hall, 26 residents on 400 hall, 19 residents on 500 hall and 18 residents on 600 hall. Assessments: 1. All residents in facility were assessed for any skin issues that might be indicative of abuse or neglect beginning at 3:00 p.m. on 2/14/13 and completed on 2/14/13. There were no issues noted on these skin assessments. 2. All cognitive residents in facility were interviewed to determine if they have been abused or neglected on 2/14/13 beginning at 3:00 p.m. and completed on 2/14/13, no issues were reported. Training: 1. All nursing staff in-serviced at the beginning of each shift, beginning on 2/14/13 at 3:00 p.m. and will be ongoing to include new hires and staff returning from leave. Training will take place before staff work on floor. Training will be done by DON/designee and in-service sign-in sheets used. Training will include verbal training on abuse, neglect, reporting and identification of staff burn out and if staff see another staff member with these signs to report it immediately to their direct supervisor and/or DON/designee. 2. Administrator has been in-serviced by Nursing Consultant regarding completion of a thorough abuse investigation on 2/14/13 at 3:00 p.m. Monitor: 1. Director of Nursing/designee will monitor body audits weekly beginning 2/14/13 to identify any issues that could be indicative of abuse or neglect, if any issue noted it will be addressed immediately. 2. Director of Nursing/designee will monitor incident and accident reports daily to (identify) any incident that could be the result of abuse, neglect (and/or) staff burn out beginning 2/14/13 and address any issue immediately. 3. Administrator/designee will interview 2 staff members on day shift, 2 staff members on evening (shift) and 2 staff members on night shift daily beginning on 2/15/13 to discuss if they have seen any staff members with signs of staff burnout or if they have staff burn out, any issue will be addressed immediately. 2. Resident #7 had [DIAGNOSES REDACTED]. a. The Office of Long Term Care (OLTC) Incident and Accident Report (I & (and) A) DMS-7734 documented, "Date and Time Submitted (if known): 12/17/12 10:45 a.m. Date & Time of Discovery: 12/16/12 11:30 p.m. ... Date of I & A: (12/16/12). Time: 11:30 a.m. Name of Resident (Resident #7) ... Status of Alleged Perpetrator: Facility Employee ... Type of Incident: Neglect ... Summary of Incident: On December 16, 2012 during 3:00 p.m. - 11:00 p.m. shift resident began accusing two male CNAs of neglecting her by failing to answer her call light after she requested an additional pillow, and that they told other staff members not to help her. She states she had her call light on for over three hours and no one answered it. She (also) told nurse she wasn't going to take any more medications from him because he was a 'lair' and was 'drugging her to abuse her'. Resident also stated to nurse she thought staff were recording her and there were cameras in the ceiling. Steps Taken to Prevent Continued Abuse or Neglect During the Investigation: ... Social Service Director interviewed resident on December 17, 2012, resident stated she felt staff were rude to her about getting her pillow and they must have told the rest of the staff because they didn't come to help her during the rest of the day. She made no indication regarding staff being neglectful or abuse as she did on Sunday, (December 16, 2012). Resident reported that CNAs (CNA #6) and (CNA #7) were the aides that were rude to her. (CNA #6) did not work Sunday, which was when she made the report. (CNA #7) did work on Sunday December 16, 2012, he will be suspended pending investigation. Resident received her medications form nurses working... Camera footage is being reviewed to determine when staff entered room. Facility is also interviewing staff who worked 12/16/12 all shifts to determine what information they have regarding this allegation. Additionally, they are being interviewed to determine what care they did deliver to resident..."

Complaint # was substantiated (all or in part) in these findings. Based on record review, and interview the facility failed to ensure the facility's abuse policy was implemented as evidenced by the facility's failures to: Ensure signs and symptoms of burn out were reported and interventions developed and consistently implemented to prevent possible abuse and failed to fully investigate staff statements obtained during the investigation of verbal and physical abuse to ensure appropriate actions were taken to protect residents from the potention of further abuse for 1 (Residents #4) of 6 (Residents #1 through 6) case mix residents who resided on the 300, 400, 500, and 600 halls where Certified Nurses Assistants (CNAs) # 1, 2, and 5 worked. These failed practices resulted in Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #4 who was verbally and physically abused by CNA #5 and had the potential to affect 71 residents who were cognitively impaired and required assistance with activities of daily living (total census: 119), as documented on a Room Bed List dated 2/26/13. The facility was informed of the Immediate Jeopardy condition on 2/14/13 at 4:05 p.m. Ensure thorough investigation of an allegation of neglect, verbal and physical abuse on the 200 hall for 1 of 1 (Resident #7) case mix resident who alleged abuse and an allegation of misappropriation of personal property on the 100 hall for 1 of 1 (Resident #8) case mix resident who made an allegation of misappropriation of property. These failed practices had the potential to cause more than minimal harm for 33 residents on 2 of 6 halls (16 residents on the 100 hall where misappropriation of property was alleged to have occurred and 17 residents on the 200 hall where neglect, verbal and physical abuse was alleged to have occurred) according to the listings provided by the Assistant Administrator on 2/15/13. Ensure a Criminal Record Check was completed for the Activity Director in accordance with State law. This failed practice had the potential to cause no more than minimal harm for all 119 residents who resided in the facility, as documented on the Room/Bed List dated 2/26/13. The findings are: 1. The facility's policy titled "Abuse Investigation (and) Reporting Policy" documented, " 1. Staff Employment Screening ... 2. Background checks. The Personnel Director or other person designated by the Administrator, will conduct criminal record checks as required by state and federal law, ... on persons who are under consideration for employment with the Facility...II. Staff Training and Competency. 1. New employee orientation. At new employee orientation, all employees will be given a copy of the Facility's Abuse Policy ... 2. Inservices. a. The Facility will conduct in-service programs at least annually for all employees reviewing the Facility's Policy and the proper procedures for protecting patients and reporting suspected or alleged abuse or neglect of patients. Attendance at in-service training programs is mandatory, and attendance will be taken and recorded. b. In-service programs may include the following information: ... ix. Stress reduction and burn-out, including how staff should intervene if other staff lose control or abuse a patient ... III. Identifying, Investigating, (and) Reporting ... 4. Identification and investigation. ... b. Interviews. Identification and investigation of abuse, neglect, or misappropriation of property should include interviews with those persons the investigator determines are related to allegation or incident. The investigator should consider interviewing persons listed below: i. Facility employees ... ii. Victim patient; iii. Patient's room mate; iv. Other patients ..." 2. Resident #4 had a [DIAGNOSES REDACTED]. a. The Office of Long Term Care (OLTC) Incident and Accident Report (I & (and) A) DMS-7734 documented "Date and Time Submitted (if known): 12/28/12 11:00 a.m. Date & Time of Discovery: 12/28/12 1:15 a.m. ... Date of I & A: 12/28/12. Time: 1:15 a.m. Name of Resident (Resident #4) ... Status of Alleged Perpetrator: Facility Employee ... Type of Incident: ... Abuse: Verbal ... Physical ... Summary of Incident: On December 28, 2012 nurse (Licensed Practical Nurse (LPN) #2) heard yelling, she went down 600 hall and found CNA (Certified Nursing Assistant (CNA) #5) yelling at resident. Aide was leaning over resident, grabbing both of his wrist, holding them against his chest and yelling, "Quit this [***] ing[***] I have to do my job." Nurse immediately intervened and removed aide from room. Nurse immediately suspended aide and removed him from facility... Steps Taken to Prevent Continued Abuse or Neglect During the Investigation: ... Administrator, Director of Nursing and Officer (name) interviewed resident on December 28. 2012 at 9:15 a.m. Resident reported that aide was trying to 'beat me up', he didn't hear the aide say anything to him because he didn't have his hearing aide in. Resident stated he was ok and did not have bruises around his wrist. He did not want to file charges against aide, he stated he hadn't had any problems with aide before. Body audit completed by treatment nurse with new findings of fresh scratch marks on left upper arm time three and area is red and raised. Marks consistent with fingernail marks. Facility is interviewing staff members who have worked with aide to determine if they witnessed any of these events. Facility is also interviewing residents who aide worked with to determine if there were any additional events that may have occurred. Facility is inservicing staff regarding abuse and neglect policy and procedure with emphasis on what to do if someone identifies abuse, protecting resident and identifying staff members that are having a change in demeanor or behavior to prevent abuse/neglect before it occurs. Employee suspended beginning on December 28, 2012 around 1:30 a.m., employees employment will be terminated based on the information obtained, however investigation will continue to complete additional interviews, in-services and monitoring of resident." b. The OLTC Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, & Exploitation of Resident in Long Term Care Facilities form DMS-762 documented, "...Date and Time of Incident (if known): 12/28/12. Time: 1:15 a.m. ... Type of Incident: ... Abuse: Verbal ... Physical ... Name of Involved Resident: (Resident #4) ... Physical Functional Level/Impairment: Resident requires assistance for all ADLs (Activities of Daily Living), Resident had left sided paralysis ... Section II - Complete Description of Incident ... On December 28, 2012 nurse (LPN #2) heard yelling, she went down 600 hall and found CNA (CNA #5) yelling at resident. Aide was leaning over resident, grabbing both of his wrist, holding them against his chest and yelling, "Quit this [***] ing[***] I have to do my job." Nurse immediately intervened and removed aide from room. Nurse immediately suspended aide and removed him from facility. Section III - Findings and Actions Taken ... Interview with resident revealed that resident did not have his hearing aides in on the morning of the incident. He did not hear what aide was telling him, he thought that the aide (was) trying to 'beat him' up and didn't know why. He said he had not had any problems with this aide before and wasn't sure why he was trying to 'beat him up'. Interview with (CNA #5) via telephone: aide did admit to yelling (at) resident and (grabbing) him, but said that resident was being resistant to care. Aide stated that he was trying to protect himself. Aide was informed that his employment had been terminated due to incident. Interview with nurse (LPN #2) confirms that she walked in on the event. She witnessed aide cursing and yelling at resident as well as him grabbing the resident. Interviews with cognitive residents did not reveal any other incidents involving this aide. Interviews with staff members did not reveal any incidents of abuse with this aide. Based on the above information facility supports the allegation of abuse and has terminated aide." The form was signed by the Administrator on 1/4/13. c. The OLTC Witness Statement Form signed by (CNA #1) documented, "Date: 12/18/12. Time: 1:15 a.m. ... Job Title: CNA. Shift 11:00 p.m. to 7:00 a.m. ... State in your own words what you witnessed (be very descriptive) and sign below: I have worked with (CNA #5) on halls before. I've seen him get impatient with residents and start to be a little rough and yell at the residents. I've seen him restrain (resident) (Resident #6) but only when (resident) was trying to punch myself or (CNA #5)... He has never hit a resident and he's good with resident, sometimes he just gets agitated." 1) The OLTC Witness Statement Form signed by (CNA #1) documented, "Date: 2/13/12. Time: 10:50 p.m... Job Title: CNA. Shift 11:00 p.m. to 7:00 a.m... State in your own words what you witnessed (be very descriptive) and sign below: To clarify 12/28/12 statement. When I said yelling I (meant) he was talking loud. I have never heard him yell cuss words at a resident. When I said little rough, moved residents fast or quickly but he never hurt anyone body." 2) On 2/14/13 at 7:12 a.m., CNA #1 was asked, "Do you have any concerns regarding abuse or neglect occurring in the facility?" CNA #3 stated, "I've seen one guy, (CNA #5). If a resident was combative he'd hold a resident down while the other aide, which was usually me, would change them." CNA #1 demonstrated the resident's arms would be crossed over the resident's chest and one hand of the aide would be placed over the crossed wrist area. CNA #1 was asked, "How often did this happen?" CNA #1 stated, "Mostly with (Resident # 6), maybe 3 times back when he first got here. Then we figured out he was combative with males only." CNA #1 was asked, "Did you think this was okay?" CNA #1 stated, "I didn't think it was okay to hold the resident, but the resident didn't complain and he (CNA #5) was gentle with holding him (Resident #6) and it kept us from getting hit or the resident from hitting his arms on the bed." CNA #1 was asked, "Did you tell anyone?" CNA #1 stated, "No, he never did anything that was abuse." CNA #1 was asked, "What are some signs of burn out or stress?" CNA #1 stated, "Yelling, cussing, tell you I don't want to be here, I don't like this job." CNA #1 was asked, "Have you seen any staff members with burnout?" CNA #1 stated, "Not since (CNA #5), no." CNA #1 was asked, "What did you do?" CNA #1 stated, "Usually I'd tell (CNA #5) to go take care of another resident so (CNA #5) didn't have to do it." CNA #1 was asked, "Did you ever hear (CNA #5) cuss residents?" CNA #1 stated, "He would cuss under his breath and when the resident would say 'What?' (CNA #5) would say 'Nothing'." CNA #1 was asked, "He did this in the presence of residents?" CNA #1 stated, "Yes." CNA #1 was asked, "Which resident?" CNA #1 stated "Which ever one was upsetting him." CNA #1 was asked, "What did you do about that?" CNA #1 stated, "I told (CNA #5) to go ahead and go I've got this resident and I told (LPN #2), our nurse and after I told her she told him, 'You can't be doing that around residents.' After that he wouldn't get residents up with me. He'd give me certain residents and he'd do the others." CNA #1 was asked, "Did you ever see (CNA #5) get impatient or rough with residents?" CNA #1 stated, "I would see him move residents up by himself, without asking for help kind of rough and I'd see him transfer residents up to the chair by himself who were a 2 person and I'd offer to help. He'd do it quicker than I liked and he'd say 'No, just hold the wheelchair'." CNA #1 was asked, "Did any resident get hurt or complain about him being rough?" CNA #1 stated, "No." CNA #1 was asked, "Did you ever see (CNA #5) restrain a resident?" CNA #1 stated "When they were being combative, he'd hold their wrist up to their chest." CNA #1 was asked, "Is it okay to hold a resident's wrist to restrain them?" CNA #1 stated, "I had thought before it was okay but I've now been told it is not." CNA #1 was asked, "Your statement dated 12/28/12, 'little rough' means what?" CNA #1 stated, "Transferring really quickly and the restraining residents by their wrist." CNA #1 was asked "What is agitated in your statement?" CNA #1 stated, "He'd restrain them more, he'd tell the resident we have to do this and come on now." CNA #1 was asked, "After you wrote the statement, did anyone talk with you?" CNA #1 stated, "Yes, (Director of Nurses (DON)) and (Administrator) called me yesterday (2/14/13) about this." CNA #1 was asked, "What did they say?" CNA #1 stated, "They questioned what the witness statement I wrote meant. What did the rough mean. I told them the holding wrist to chest, restraining them, pulling them up in bed, moving them from bed to wheelchair faster." CNA #1 was asked, "Did they say anything else?" CNA #1 stated, "They asked me to come in and write another statement." CNA #1 was asked, "Was any counseling or warning done with you?" CNA #1 stated, "No." 3) On 2/14/13 at 10:00 a.m. this Surveyor requested the employee file and disciplinary counselings for CNA #1. 4) On 2/14/12 at 12:10 p.m. the employee file for CNA #1 was reviewed. The Employee Disciplinary Action form for CNA #1 documented, "Date of Occurrence: 2/14/13. Date of Counseling: 2/14/13. Type of Action: Verbal ... Description of Occurrence: Failure to report allegations of abuse or neglect... Corrective Action Taken: Re-inservice on abuse and neglect... Spoke with aide via telephone on 2/13/13 regarding reporting anything that she felt could possibly be considered abuse. Gave aide formal write up on 2/14/13." The back side of the Employee Disciplinary Action form documented, "Spoke with CNA in December regarding her statement made regarding (CNA #5). Received clarification about her meaning of 'rough' and 'yelling'. At that time discussed with aide the importance of reporting any behaviors or issues that could be possibly considered abuse or neglect." The form was signed by the Administrator with date of 12/28/12 documented. d. The OLTC Witness Statement Form signed by (CNA #2) documented, "Date: 12/18/12. Time: (Blank) ... Job Title: CNA. Shift 11:00 p.m. to 7:00 a.m. ... State in your own words what you witnessed (be very descriptive) and sign below: I have worked with (CNA #5) before. I've seen him start to get agitated with residents but never let it escalate to more. If I notice he's getting worked up I have him leave the room or I try to talk to resident..." 1) On 2/14/13 at 7:55 a.m. CNA #2 was asked, "What are some of the signs of staff burn out or stress?" CNA #2 stated, "They don't care as much, just in and out." CNA #2 was asked "Have you seen any staff members with burn out?" CNA #2 stated, "No." CNA #2 was asked, "Did you ever work with (CNA #5)?" CNA #2 stated, "Yes." CNA #2 was asked "Did you ever see (CNA #5) get impatient or rough with residents?" CNA #2 stated, "Any time I saw him get impatient, I'd tell him to leave..." CNA #2 was asked, "What do you mean by impatient?" CNA #2 stated, "(CNA #5's) facial expressions would change, he'd get upset." CNA #2 was asked, "Your statement dated 12/28/12, who 'never let it escalate'?" CNA #2 stated, "I never let it escalate." CNA #2 was asked, "Did you talk with any one about (CNA #5)?" CNA #2 stated, "No, he never really did anything. I'd either send (CNA #5) out or talk to the resident and distract them and (CNA #5) would be okay." CNA #2 was asked, "How often did you tell him to leave?" CNA #2 stated, "I only worked with him for about a month?" CNA #2 was asked, "How many times did you tell him to leave?" CNA #2 stated, "Maybe twice. I'd tell (CNA #5) to leave or I'd tell (CNA # 5) I'd do the resident from now on. You have to understand that it was only with (Resident #6)." 2) On 2/14/13 at 10:00 a.m., this surveyor requested the employee file and disciplinary counselings for CNA #2. 3) On 2/14/12 at 12:10 p.m. the employee file for CNA # 2 was reviewed. There were no documented disciplinary counselings or inservices in this employee's file. e. The OLTC Witness Statement Form signed by LPN #2 documented, "Date: 12/18/12. Time: 1:15 a.m. ... Job Title: LPN. Shift Night (11:00 p.m. to 7:00 a.m.) ... State in your own words what you witnessed (be very descriptive) and sign below: I was sitting (at) nurse's station, heard CNA yelling, went down hall (and) found CNA in (Resident #4's) room. CNA was leaning over resident, grabbing both of (resident's) wrist, holding them against his chest (and) yelling (at) (resident). Overheard CNA telling (resident) to 'Quit this [***] ing[***] I have to do my job.' I intervened (and) had CNA let go of (resident), before CNA could back away, (resident) grabbed CNA's scrub top and tried to pull him closer, obviously upset. Asked CNA to leave room (and) clocked out about 1:30 a.m." On 2/14/13 at 7:42 a.m. LPN #2 was asked, "What are some of the signs of staff burnout?" LPN #2 stated, "Personality change, short temper, snappy." LPN #2 was asked, "When you see signs of burn out what do you do?" LPN #2 stated, "I send them out for a breather, get another CNA to help or I go help while the other CNA is gone. If it's excessive and a break doesn't help, I have them talk with CNA supervisor (Lead CNA) and I talk with CNA supervisor." LPN #2 was asked, "Do you tell the DON (Director of Nursing) or Administrator?" LPN #2 stated "If it's excessive, yes." LPN #2 was asked, "Have you ever heard a CNA yell at a resident?" LPN #2 stated, "I have once." LPN #2 was asked, "Who?" LPN #2 stated "(CNA #5), he no longer works here." LPN #2 was asked, "What did you do?" LPN #2 stated, "I sent him home that night." LPN #2 was asked, "Ever see (CNA #5) get impatient or rough with a resident?" LPN #2 stated, "Not before this incident. He wasn't on my hall and I didn't work with him a lot." LPN #2 was asked, "Who was his LPN mostly?" LPN #2 stated, "(LPN #1), she's 3:00 p.m. to 11:00 p.m. now." LPN #2 was asked, "Did any CNAs report concerns with (CNA #5) before this incident?" LPN #2 stated, "No, not that I remember." LPN #2 was asked, "Did you ever hear CNAs telling (CNA #5) to go and take a break when he looked stressed?" LPN #2 stated, "No." f. There were no other 11:00 p.m. to 7:00 a.m. staff interviews or resident interviews documented. g. On 2/11/13 at 12:45 p.m. the Inservice Education Report that was part of this abuse allegation investigation received from the Administrator was copied. The Inservice Education Report dated 12/18/12 documented, "... Topics: Abuse and Neglect: See attached handout. 7 types of abuse: physical, mental, verbal, sexual, involuntary seclusion, misappropriation of property and neglect. Identifying - If you witness abuse you must report immediately; Anyone who sees or hears abuse must report immediately. In order to protect residents that are possible victims of abuse the alleged staff member is suspended immediately and if the alleged perpetrator is not identified then the resident will receive care in pairs." There were no signatures of any staff members on the sign in sheet. The attached handout did not include signs/symptoms of burn out and who to report possible burnout to. On 2/11/13 at 12:45 p.m. a second Inservice Education Report that was part of this abuse allegation investigation received from the Administrator was copied. The Inservice Education Report dated 12/18/12 documented, "... Topics: Abuse and Neglect: See attached handout. 7 types of abuse: physical, mental, verbal, sexual, involuntary seclusion, misappropriation of property and neglect. Identifying - If you witness abuse you must report immediately; Anyone who sees or hears abuse must report immediately. In order to protect residents that are possible victims of abuse the alleged staff member is suspended immediately and if the alleged perpetrator is not identified then the resident will receive care in pairs." There was one signature on the sign in sheet, which was not CNA #1 or 2. The attached handout did not include signs/symptoms of burn out and who to report possible burnout to. h. On 2/13/13 at 1:50 p.m., the Administrator was asked for inservices on abuse/neglect done since 12/1/12. On 2/13/12 at 3:00 p.m. an Inservice Education Report was received from the Administrator and was copied. The Inservice Education Report dated 12/18/12 documented "... Topics: Abuse and Neglect: See attached handout. 7 types of abuse: physical, mental, verbal, sexual, involuntary seclusion, misappropriation of property and neglect. Identifying - If you witness abuse you must report immediately; Anyone who sees or hears abuse must report immediately. In order to protect residents that are possible victims of abuse the alleged staff member is suspended immediately and if the alleged perpetrator is not identified then the resident will receive care in pairs." There were seventeen signatures on the sign in sheet, which did not include CNA #1 or 2. The attached handout did not include signs/symptoms of burn out and who to report possible burnout to. On 2/13/12 at 3:00 p.m. a second Inservice Education Report was received from the Administrator and was copied. The Inservice Education Report dated 1/3/13 documented "... Topics: Dress Code: ... Abuse and Neglect and Misappropriation of property. 1. If you know of any type of abuse, neglect or stolen property report it immediately to supervisor. 2. Always protect resident. 3. Keep aware of any changes in resident because this could be a result of possible abuse. 4. Communicate with each other and residents regarding any changes in residents." There were 64 signatures on the sign in sheet, which did not include CNA #1 or 2. The inservice did not include signs/symptoms of burn out and who to report possible burnout to. i. On 2/13/13 at 3:20 p.m. LPN #1 stated she had worked in the facility since August 2012 on the 400, 500, and 600 halls. LPN #1 stated she had been working on the 3:00 p.m. to 11:00 p.m. shift since 12/15/12. LPN #1 stated prior to this she worked the 11:00 p.m. to 7:00 a.m. shift. LPN #1 was asked, "What are the signs of possible burn out that you might see from staff members?" LPN #1 stated, "Frazzled, look stressed, tone of voice sharp, harsh." LPN #1 was asked, "Did you ever work with (CNA #5)?" LPN #1 stated, "Yes a few times". LPN #1 was asked, "How long ago?" LPN #1 stated, "Sometime before the middle of December." LPN #1 was asked, "Did you ever hear (CNA #5) yell at residents?" LPN #1 stated, "I didn't hear him yell. He was an older man, his tone sometimes came across as aggressive. We had addressed it before with him." LPN #1 was asked, "Addressed it?" LPN #1 stated, "You could hear it in his voice when he got overwhelmed and we'd say 'It's okay (CNA #5), we'll get you some help, we'll get through it." LPN #1 was asked, "What do you mean by aggressive tone?" LPN #1 stated, "Not patient, louder." LPN #1 was asked, "Did that happen often?" LPN #1 stated, "Not often." LPN #1 was asked, "How frequently did it happen?" LPN #1 stated, "I addressed it with him twice in the few months I worked with him." LPN #1 was asked, "Did you report his behavior to any one else?" LPN #1 stated, "Yes, to the lead CNA. We passed it on that he had gotten frazzled." LPN #1 was asked, "Is that the chain of command with CNAs, that you report problems to the lead CNAs?" LPN #1 stated, "Yes and if I don't think the problem is being addressed I mention it to my DON." LPN #1 was asked, "Who is the lead CNA you talked with?" LPN #1 stated "(Lead CNA #1) and (Lead CNA #2)." LPN #1 was asked, "Did you talk with the DON regarding (CNA #5)?" LPN #1 stated, "No." j. On 2/14/13 at 8:17 a.m., CNA #3, who worked the 11:00 p.m. to 7:00 a.m. shift, on the 400, 500, and 600 halls, was asked, "Did you ever work with (CNA #5)?" CNA #3 stated "Yes." CNA #5 was asked, "Did you ever hear (CNA #5) cuss a resident?" CNA #3 stated, "No." CNA #3 was asked, "Did you ever hear him cuss under his breath when taking care of a resident?" CNA #5 stated, "Yes, I heard him say 'Damn it' once when he was done with a resident. I only worked with him a few times, maybe three, he never cussed at a resident, it was more like 'Holy[***]this job sucks'." CNA #3 was asked, "Did you tell anyone?" CNA #3 stated, "No." k. On 2/14/13 at 10:22 a.m., CNA #4 was asked, "What are some of the signs of staff burn out or stress?" CNA #4 stated, "Not as fast with care, more smoke breaks, facial expressions change, body language tense." CNA #4 was asked, "What would you do if you noticed signs of burn out/stress?" CNA #4 stated, "Ask the person if they are okay, tell the Lead CNA." l. On 2/14/13 at 10:35 a.m. Lead CNA #1 was asked, "What are some of the signs of staff burn out or stress?" Lead CNA #1 stated, "Walk the halls, don't want to be here, complain too much." Lead CNA #1 was asked, "Have you seen any staff members with burn out?" CNA #1 stated, "Yes, a second shift (3:00 p.m. to 11:00 p.m.) CNA was complaining so much that I asked if she was okay. She said she was. I think her frustration was with the new NA (Nurses Assistant)." Lead CNA #1 was asked, "For burn out or stress what do you do?" Lead CNA #1 stated, "Talk with the CNA and report to the DON." Lead CNA #1 was asked, "Did the night shift staff, CNAs or LPNs, come to you with concerns regarding (CNA #5)?" Lead CNA #1 stated, "No." m. On 2/14/13 at 10:43 a.m. Lead CNA #2 was asked, "What are some of the signs of staff burn out or stress?" Lead CNA #2 stated, "Facial expression, body language, and attitude change." Lead CNA #2 was asked, "Have you seen any staff members with burn out?" Lead CNA #2 stated, "No, nothing major." Lead CNA #2 was asked, "What did you do?" Lead CNA #2 stated, "If I think they may have burn out, I ask them. I offer to move them from the hall they are on, ask if they need a break. I tell the DON when I notice burn out." Lead CNA #2 was asked, "Did any of the night shift CNAs ever report concerns about (CNA #5)?" Lead CNA #2 stated, "No." Lead CNA #2 was asked, "Did any night shift LPNs report concerns with (CNA #5)?" Lead CNA #2 stated "No." n. On 2/14/13 at 10:57 a.m. LPN #3 stated she worked the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shifts on the 400, 500, and 600 halls. LPN #3 was asked, "What are some of the signs of burn out?" LPN #3 stated, "Irritability, lack of attention to residents, don't spend time with residents, frequent breaks, a lack of quality in their work." LPN #3 was asked, "What do you do when you see signs of burn out?" LPN #3 stated, "Talk to them, if working too many hours tell the Lead CNA to cut back on hours and give them time off." o. On 2/14/13 at 1:50 p.m. the Administrator was asked to review the investigation for Resident #4. The Administrator was asked, "You got statements from how many CNAs and LPNs?" The Administrator stated, "(CNA #1), (CNA #2), and (LPN #2)." The Administrator was asked, "Did you do any resident interviews?" The Administrator stated, "We have body audits my treatment nurse did that day." The Administrator was asked, "Are there interviews from other residents?" The Administrator stated, "We did them. I don't know why they aren't in here." The Administrator was asked, "What did you do when you read (CNA #1's) statement?" The Administrator stated, "We called her and clarified rough as he was moving him quickly. I should have had her write another statement and this a.m. we did a verbal write up. We looked at this again yesterday when you said you needed this back today." The Administrator was asked, "We?" The Administrator stated, "(DON) and me." The Administrator was asked, "Do you know of anyone talking to (CNA #5) prior to 12/28/12 about his tone, etc.?" The Administrator stated, "I'll have to look." As of 2/15/13 at 12:30 p.m., the Administrator had not provided any counselings for CNA #5 other than the termination done on 12/28/12. The Administrator was asked, "On the inservice dated 1/3/13, did you cover signs/symptoms of burn out?" The Administrator stated, "It's not written down but I usually cover it." The Administrator was asked, "Was (CNA #1) in-serviced after this on the 1/3/13 or 12/28/13 inservices on abuse or neglect?" The Administrator stated "No." The Administrator was asked, "Was (CNA #2) inserviced on abuse or neglect after statement?" The Administrator stated, "No." p. On 2/14/13 at 2:35 p.m. the Social Service Director was asked, "Did you do any resident interviews regarding staff cussing, yelling or rough treatment, etc. after this happened on 12/28/12?" The Social Service Director stated, "No." q. On 2/14/13 at 2:40 p.m. the DON was asked, "Did you see (CNA #1's) or (CNA #2's) statements before yesterday?" The DON stated, "I can't tell you with 100% accuracy if I did or not. Not up until yesterday and I know I reviewed them then." The DON was asked "What does (CNA #1's) statement say to you?" The DON stated, "There's a history and she's not reporting abuse and neglect." The DON was asked, "Did you talk with (CNA #1) before yesterday about her statement?" The DON stated, "I don't recall." The DON was asked, "What about (CNA #2's) statement?" The DON stated, "There's a problem there too." The DON was asked, "Did (LPN #1) talk to you about (CNA #5) being 'aggressive' before this happened on 12/28/12?" The DON stated, "Never." r. The Immediate Jeopardy was removed and the scope/severity reduced to "E" on 2/14/13 when the facility implemented the following Plan of Removal: Identification: 1. Residents at risk for this failed practice include 24 residents on 300 hall, 26 residents on 400 hall, 19 residents on 500 hall and 18 residents on 600 hall. Assessments: 1. All residents in facility were assessed for any skin issues that might be indicative of abuse or neglect beginning at 3:00 p.m. on 2/14/13 and completed on 2/14/13. There were no issues noted on these skin assessments. 2. All cognitive residents in facility were interviewed to determine if they have been abused or neglected on 2/14/13 beginning at 3:00 p.m. and completed on 2/14/13, no issues were reported. Training: 1. All nursing staff in-serviced at the beginning of each shift, beginning on 2/14/13 at 3:00 p.m. and will be ongoing to include new hires and staff returning from leave. Training will take place before staff work on floor. Training will be done by DON/designee and in-service sign-in sheets used. Training will include verbal training on abuse, neglect, reporting and identification of staff burn out and if staff see another staff member with these signs to report it immediately to their direct supervisor and/or DON/designee. 2. Administrator has been in-serviced by Nursing Consultant regarding completion of a thorough abuse investigation on 2/14/13 at 3:00 p.m. Monitor: 1. Director of Nursing/designee will monitor body audits weekly beginning 2/14/13 to identify any issues that could be indicative of abuse or neglect, if any issue noted it will be addressed immediately. 2. Director of Nursing/designee will monitor incident and accident reports daily to (identify) any incident that could be the result of abuse, neglect (and/or) staff burn out beginning 2/14/13 and address any issue immediately. 3. Administrator/designee will interview 2 staff members on day shift, 2 staff members on evening (shift) and 2 staff members on night shift daily beginning on 2/15/13 to discuss if they have seen any staff members with signs of staff burnout or if they have staff burn out, any issue will be addressed immediately. 3. Resident #7 had

Complaint # and substantiated (all or in part) in these findings. Based on observation, record review, and interview, the facility failed to ensure the physician was promptly consulted regarding drainage and deterioration in a pressure ulcer and to ensure a pressure relieving mattress was in place to decrease the risk of further skin breakdown for 1 (Residents #6) of 3 (Residents #6, 7, and 8) case mix residents who had pressure ulcers. These failed practices resulted in a pattern of actual harm for Resident #6 who had documented purulent drainage for 22 days prior to hospitalization for septic shock and gangrene of the pressure ulcer and had the potential to cause more than minimal harm for 6 residents who had pressure ulcers according to the list received from the Administrator on 6/6/12. The findings are: 1. The facility policy titled "Charting and Documentation" documented, "All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. ... 1. All observation ... services performed, etc., must be documented in the resident's clinical records. ... 3. All ... changes in the resident's condition must be recorded. ... 6. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: ... c. The assessment data and/or any unusual findings obtained during the procedure/treatment; ... f. Notification of family, physician or other staff, if indicated ..." The facility policy title "Pressure Ulcer Prevention" documented, "Residents admitted to our facility shall be assessed for the presence of pressure ulcers of other skin breakdown. ... Interventions to eliminate or minimize risk factors will be introduced at the earliest possible time...." The facility policy titled "Routine Care/Prevention Protocol" documented, "... Wound Definitions and Characteristics: ... Suspected Deep Tissue Injury - Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear. ... Stage II - partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough ... Stage III - Full thickness tissue loss. ... Slough may be present but does not obscure the depth of tissue loss. ... Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling ... Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed. Further description - Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined ..." 2. Resident #6 had [DIAGNOSES REDACTED]. The "(Hospital) History and Physical" dated 4/18/12 at 11:34 p.m. documented, "(Resident #6) is a 81 (year old) female ... who presents for evaluation of infected legs. (Patient) has severe Dementia. She has not gotten out of her recliner since December 2011 ... Today family noted very malodorous and worsening [DIAGNOSES REDACTED] of (lower extremities) and decided to take to the doctor ... She has maggots growing between her toes and likely has a decubitus ulcer as well. ... Skin: Marked (lower extremity) [MEDICAL CONDITION] to buttock ... Patient Active Hospital Problem List: ... [MEDICAL CONDITION] and abscess of leg ... [MEDICAL CONDITION] ... Maggot infestation - wound care consult ..." The "Wound Care Consult" dated 4/19/12 at 10:56 a.m. documented, "... Assessment: Skin assessment done, noted multiple wounds to leg, foot, thighs and bilateral buttocks. ... #3: Right posterior lower leg: venous stasis ulcerations. ... #4: Stage (pressure ulcer) to the left coccyx ... Plan: 1. Low air loss mattress ..." The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/2/12 documented the resident scored an 8 (8 - 12 indicates moderately impaired) on the Brief Interview for Mental Status, required extensive assistance of two plus persons for bed mobility and toilet use, was always incontinent of urine and bowel, had no infections in the past 7 days, was at risk for pressure ulcers, and had two Stage 2 pressure ulcers that were present on admission. a. The (Hospital) Discharge Instructions dated 4/25/12 documented, "... Patient Care Instructions: Continue wound care per following instructions. ... Removed [MEDICATION NAME] from sacral area, washed buttocks ... Observed 3 - 4 scattered small shallow stage 2 (pressure ulcers), some granulation present but slow to heal. Sacral area surrounding remains non-blanchable and may represent deeper tissue damage. ... Right buttock ... Observed a few shallow tears from probable shear and moisture ... Low air loss mattress." b. The "Resident Data Collection" form for admitted d 4/25/12 at 4:50 p.m. documented, "... Skin Condition: See Nurse's Notes." A physician order [REDACTED]." The "Nurse's Notes" dated (4/26/12) at 12:20 a.m. documented, "Resident was admitted ... at 4:50 p.m. ... 3+ (plus) [MEDICAL CONDITION] noted in all extremities. Most of skin appears reddened ... Buttocks Stage 2 ..." c. The "Braden Scale - For Predicting Pressure Sore Risk" dated 4/26/12 documented a score of 12 (10 to 12 indicates high risk). d. The "Weekly Wound Assessment" form, written by the Treatment Nurse, dated 4/26/12 documented, "... Wound Location: (Left) Buttock (Sacral area); How acquired: Present on admission ... Wound Type: Pressure ... Stage: 2; Size L (length) x (by) W (width) x D(depth): L: 1.0 cm (centimeters); W: 1.0 cm ; D: 0.1 cm ... Exudate: None ... Surrounding tissue: [DIAGNOSES REDACTED]tous; Treatment Order: Cleanse (with) safe-clens, pat dry (with) 4 x 4's, apply [MEDICATION NAME] signal (every) 3 (days) (as needed)." Physician orders [REDACTED]. ... Cleanse pressure to (left) buttock (sacral) (with) safe-clens, pat dry, apply [MEDICATION NAME] signal (every) 3 days (as needed). ..." e. The "Weekly Wound Assessment" form, written by the Treatment Nurse, dated 5/1/12 documented, "... Location: (Left) Buttock (Sacral area); Stage/Thickness: 2; Size ...: L: 17.2 cm; W: 8.0 cm; D: 0.1 cm ... Exudate: Present; Color: Purulent; Amount: Large; Odor: None ... Wound Bed Appearance: Slough ... Surrounding tissue: [MEDICAL CONDITION], [DIAGNOSES REDACTED]tous, Induration, Discoloration ... Interventions: ... Pressure redistribution surface ...; Treatment Order: (Treatment) order (changed), Cleanse (with) safe-clens, pat dry, apply [MEDICATION NAME], cover (with) [MEDICATION NAME] signal daily (Physician order [REDACTED]. Comments: Resident (left) buttock is discolored (with) small amount slough." On 6/6/12 at 2:40 p.m. the Treatment Nurse was asked, "(Resident #6), did she have any decubitus present on admit?" The Treatment Nurse stated, "One on the right buttock and one on the left buttock." The Treatment Nurse was asked, "What were the stages on admit?" The Treatment Nurse stated, "Stage 2." The Treatment Nurse was asked, "Tell me about the left buttock/sacral area." The Treatment Nurse stated, "Patient cane in with a Stage 2. I treated it for a couple of days and then I came back on Monday, 4/30/12 and they reported (Resident #6) did not want to turn and would not stay off her back. On 5/1/12, I found it had changed. I found it on the 30th but I didn't measure it or change treatment until 5/1/12." The Treatment Nurse was asked, "Did you notify the doctor of the drainage being purulent and a large amount?" The Treatment Nurse stated, "Yes, I told (Advanced Practice Nurse (APN)) and I let the charge nurse know - (Licensed Practical Nurse (LPN) #1)." The Treatment Nurse was asked, "Discolored - what does that mean?" The Treatment Nurse stated, "She had a tiny spot of eschar in the center of it. It was surrounded by a dark purplish color then an opened area with granulation, then normal tissue. The eschar and discolored tissue are unstageable so you don't know what's underneath those." The Treatment Nurse was asked, "Then why did you stage it as a 2, if you know eschar is unstageable?" The Treatment Nurse stated, "Because when she came in it was a stage 2." The Treatment Nurse was asked, "Did you document your discussion with the APN anywhere?" The Treatment Nurse stated, "Not in here (copy of wound progress notes), I might have in the nurse's notes." The Treatment Nurse left the room to get Resident #6's chart. The Treatment Nurse returned at 3:05 p.m. with Resident #6's chart, looked at the nurse's notes and then stated, "I don't see it." The Treatment Nurse was asked, "Do you normally document physician notification?" The Treatment Nurse stated, "Normally I document about notifying the nurse ... I think I even called the family about her wounds but I didn't chart it." f. The "Wound Progress Notes" dated 5/3/12 at 3:00 p.m., written by the Treatment Nurse, documented, "(Dressing) (left) buttock (sacral area) removed. Large amount serosanguinous (drainage) ..." The "IDT (Interdisciplinary Team) Notes" dated 5/3/12, written by the Treatment Nurse, documented, "Resident admitted with Stage 2 pressure (left) buttock 17.2 x (by) 8.0 x 0.1 cm (centimeter). (right) buttock 2.0 x 1.5 x 0.1 cm. (Patient) non-compliant with turning ... (Left) buttock declined ..." g. A physician order [REDACTED]. Cleanse (left) buttock (sacral area) (with) safe-clens, pat dry, apply Santyl to eschar. Apply [MEDICATION NAME] AG cover (with) 4 x 4's, Merispore tape daily." The "Wound Progress Notes" dated 5/6/12 at 11:30 a.m., written by the Treatment Nurse, documented, "(Patient's) dressing off, wound moderate amount purulent drainage, (no) odor. Cleansed with safe clens, pat dry, Santyl applied to eschar in middle of wound bed ..." h. The "Wound Progress Notes" dated 5/7/12 at 8:30 a.m., written by the Treatment Nurse, documented, "... has eschar to mid upper wound, slough to lower area ... Has moderate amount of exudate, purulent to dressing ..." i. The "Weekly Wound Assessment" form, written by the Treatment Nurse, dated 5/8/12 documented, "... Location: (Left) Buttock (Sacral area); Stage/Thickness: 4; Size ...: L: 14.5 cm; W: 11.2 cm; D: 0.1 cm ... Exudate: Blank ... Wound Bed Appearance: Slough, Eschar ... Surrounding tissue: [MEDICAL CONDITION], [DIAGNOSES REDACTED]tous, ... Discoloration ... Interventions: ... Pressure redistribution surface ...; Treatment Order: (New Order) Santyl eschar, slough, [MEDICATION NAME] AG ..." On 6/6/12 at 2:40 p.m. the Treatment Nurse was asked, "What happened the week of 5/8/12?" The Treatment Nurse stated, "It got a little smaller but the center eschar got worse." The Treatment Nurse was asked, "How can I tell that from your measurements, documentation?" The Treatment Nurse stated, "You can't." The Treatment Nurse was asked, "Was there any drainage that week - you didn't document any?" The Treatment Nurse stated, "It did." The Treatment Nurse was asked, "What was the drainage like?" The Treatment Nurse stated, "Purulent, it was a moderate amount." The Treatment Nurse was asked, "Any odor?" The Treatment Nurse stated, "No." The Treatment Nurse was asked, "Did you do anything new for treatments?" The Treatment Nurse stated, "Turned every two hours, do treatments daily, changed treatment to Santyl and [MEDICATION NAME]." The Treatment Nurse was asked, "Where did the [MEDICATION NAME] go?" The Treatment Nurse stated, "On good tissue and outer edges." The Treatment Nurse was asked, "Did you talk with anyone about the wound getting worse on 5/8/12?" The Treatment Nurse stated, "The charge nurse, (DON, Certified Dietary Manager), and ... APN knew." The Treatment Nurse was asked, "Did you document that anywhere?" The Treatment Nurse stated, "No." j. The "IDT (Interdisciplinary Team) Notes" dated 5/11/12, written by the Treatment Nurse, documented, "... Turn (every) two hours ... (Patient) has pressure to (left) buttock Stage 2, that is non-healing, pressure (right) buttock Stage 2, non-healing ..." k. The "Weekly Wound Assessment" form, written by the Treatment Nurse, dated 5/14/12 documented, "... Location: (Left) Buttock (Sacral area); Stage/Thickness: 4; Size ...: L: 14.0 cm; W: 7.5 cm; D: 0.1 cm ... Exudate: Present; Color: Purulent; Amount: Moderate; Odor: None ... Wound Bed Appearance: Slough, Eschar ... Surrounding tissue: [MEDICAL CONDITION], [DIAGNOSES REDACTED]tous, ... Discoloration ... Interventions: ... Pressure redistribution surface ..." On 6/6/12 at 2:40 p.m. the Treatment Nurse was asked, "The week of 5/14/12, how was the wound?" The Treatment Nurse stated, "(Resident #6) let us turn her and the wound got some better, still with eschar and drainage." The Treatment Nurse was asked, "What was the drainage like?" The Treatment Nurse stated, "Yellowish brown, yellowish with specks of brown." The Treatment Nurse was asked, "Any odor?" The Treatment Nurse stated, "No." The Treatment Nurse was asked, "What do you mean by moderate amount of drainage?" The Treatment Nurse stated, "Half of 4 by 4 with drainage on it." l. The "Pressure Ulcer (Interdisciplinary Care Plan) dated 4/25/12 and reviewed on 5/11/12 documented, "Resident had pressure ulcer(s) ... (Right) buttock, Stage 2; (Left) buttock, Stage 2; related to immobility, incontinence, nutritional status, [MEDICAL CONDITION], ... Approach: ... Provide pressure relieving or reduction device: Pressure reduction mattress (not checked) ... Chair cushion (checked) ... Other: Turn (every) two (hours) (checked)." The "Skin Integrity (Interdisciplinary Care Plan)" dated 4/25/12 and updated on 5/18/12 documented, "Resident is at risk for skin breakdown related to immobility, incontinence, nutritional status, [MEDICAL CONDITION] ... Current ulcer: (Left) buttock ((right) buttock resolved 5/18/12) ... Approach: ... Provide pressure relieving or reduction device: Pressure reduction mattress (not checked) ... Chair cushion (checked) ..." m. The "Weekly Wound Assessment" form, written by the Treatment Nurse, dated 5/21/12 documented, "... Location: (Left) Buttock (Sacral area); Stage/Thickness: 4; Size ...: L: 14.0 cm; W: 7.5 cm; D: 0.1 cm ... Exudate: Present; Color: Purulent; Amount: Moderate; Odor: None ... Wound Bed Appearance: Slough, Eschar ... Surrounding tissue: ... Induration, Discoloration ... Interventions: ... Pressure redistribution surface ... Treatment Order: (Continue) (Treatment)." On 6/6/12 at 2:40 p.m. the Treatment Nurse was asked, "The week of 5/21/12, how was the wound?" The Treatment Nurse stated, "It did change, but (Resident #6) quit eating." The Treatment Nurse was asked, "Any change in the drainage?" The Treatment Nurse stated, "No, except I think it was thicker drainage." n. The "Wound Progress Notes" dated 5/23/12 at 3:00 p.m., written by the Treatment Nurse, documented, "(Patient's) buttock (sacral area) starting to debride." o. The "IDT (Interdisciplinary Team( Notes" dated 5/24/12, written by the Treatment Nurse, documented, "(Patient) (continues to) have pressure (Stage) 2 to (left) buttock 14.0 x 7.5 x 0.1 cm. (Patient) turned (every) 2 (hours) ..." p. The "Weekly Wound Assessment" form, written by the Treatment Nurse, dated 5/30/12 documented, "... Location: (Left) Buttock (Sacral area); Stage/Thickness: 4; Size ...: L: 12.0 cm; W: 4.5 cm; D: 1.5 cm ... Exudate: Present; Color: Purulent; Amount: Large; Odor: None ... Wound Bed Appearance: Slough, Eschar ... Surrounding tissue: [MEDICAL CONDITION], [DIAGNOSES REDACTED]tous, Induration, Discoloration ... Interventions: ... Pressure redistribution surface ...Treatment Order: (Continue) (treatment). Comments: Wound [MEDICATION NAME]." The "Wound Progress Notes" dated 5/30/12 at 11:45 a.m., written by the Treatment Nurse, documented, "(Patients) (dressing) on, draining through on brief, removed, large amount of purulent drainage, ... eschar loose ..." On 6/6/12 at 2:40 p.m. the Treatment Nurse was asked, "Any measurements between 5/21/12 and 5/30/12?" The Treatment Nurse stated, "I may have been off ..." The Treatment Nurse was asked, "On 5/30/12, what did the wound look like?" The Treatment Nurse stated, "It started [MEDICATION NAME] and slough was coming loose." The Treatment Nurse was asked, "Besides the increased amount drainage that you documented, was there any other change in the drainage?" The Treatment Nurse stated, "No." The Treatment Nurse was asked, "What was the color of the drainage?" The Treatment Nurse stated,, "Yellowish color." The Treatment Nurse was asked,, "Any odor?" The Treatment Nurse stated, "No." The Treatment Nurse was asked, "Any increase in depth of the wound?" The Treatment Nurse stated, "Yes." The Treatment Nurse was asked, "Did you check it for undermining, tunneling?" The Treatment Nurse stated, "No." The Treatment Nurse was asked, "Did you let anyone know it was deeper?" The Treatment Nurse stated, "I think I talked with (LPN #1)." The Treatment Nurse was asked, "Why talk with the charge nurse, he can't change the orders for wound care?" The Treatment Nurse stated, "Because we usually consult about whether or not we call the doctor." The Treatment Nurse was asked, "Did you decide to call the doctor?" The Treatment Nurse stated, "No, when she (APN) comes in we usually consult with her. We make a list and let her know what's going on." q. The "Wound Progress Notes" dated 5/31/12 at 3:00 p.m., written by the Treatment Nurse, documented, "(Patient) has slough loose, around edge of wound edges, large amount of drainage purulent ..." r. The "IDT (Interdisciplinary Team) Notes" dated 6/1/12, written by the Treatment Nurse, documented, "(Patient) (continues to) have pressure to (left) buttock 12.0 x 4.5 x 1.5 cm. (Patient) declined ... (Patient) turned (every) 2 (hours), turns back on back. Supported (with) pillows daily ... Wound is being debrided ..." The "CNA (Certified Nursing Assistant) Closet Care Plan" dated 6/1/12 documented, "... Skin: ... Currently has wound located: buttock and legs and feet ... Special Devices: None ..." On 6/6/12 at 2:40 p.m. the Treatment Nurse was asked, "Did you see the wound again after 5/30/12?" The Treatment Nurse stated, "On 6/1/12." The Treatment Nurse was asked, "How was the wound on 6/1/12?" The Treatment Nurse stated, "I didn't note it." The Treatment Nurse was asked, "On 5/31/12 you documented (Resident #6) was having pain, was that different?" The Treatment Nurse stated, "Yes, I think it was. She would refuse pain meds so I asked the nurses to call and get a routine pain med. I called the next day and got an order for [REDACTED].?" The Treatment Nurse stated, "No." s. The "Daily Skilled Nurse's Notes" dated 6/3/12 at 12:30 a.m. documented, "... wound has foul odor, DON aware ..." A physician order [REDACTED]." t. The "Nurse's Notes" dated 6/4/12 documented, "... Pressure ulcer solid (with) brownish green drainage, very foul odor noted. Copious amounts of exudate on (dressing) (and) bed sheets ..." The "Care Plan Conference Summary" dated 6/4/12 documented, "... Called (family) on Friday 6/1/12 to tell the about new wound and her not eating, Care Plan set up for today to discuss options. (Resident) sent to hospital today and admitted ..." u. The (Hospital) (Emergency Department) Provider Notes dated 6/4/12 at 8:35 am. documented, "... History of Present Illness: ... presents to the (Emergency Department) with a Chief Complaint of Altered mental status ... Patient Active Problem List: Septic Shock ... Physical Exam: ... [MEDICAL CONDITION]: Large purulent, foul smelling, necrotic decubitus with surrounding [MEDICAL CONDITION], skin breakdown on buttocks ... Clinical Impression: Gangrene with decubitus ulcer ..." The (Hospital) Wound Care Consult dated 6/4/12 at 9:37 a.m. documented, "... Assessment: This patient is known to this RN (Registered Nurse). Consulted on this patient in April 2012. At that time she had multiple wounds, the most significant was a stage two PU (pressure ulcer) to the right coccyx measuring 5.6 x 4.8 x 0.2 cm, now presents with same wound but it is a stage 4. Awaiting surgical consult for debridement to do measurements of current wound. Wound bed is foul smelling, necrotic. 100% slough, palpate bone, has tunnel at 11 o'clock as well ..." The (Hospital) History and Physical dated 6/4/12 at 3:02 p.m. documented, "... Subjective: ... She has open (decubitus) on coccyx draining thick brownish material with a very foul odor. Wound (culture) pending ... Assessment: Principal Problem:[MEDICAL CONDITION]: Source most likely being (decubitus) on coccyx ..." The (Hospital) Operative Report dated 6/4/12 at 4:53 p.m. documented, "... (Wound measurements) 15 cm x 7 cm x 5 cm ... Procedure: The (patient) was in the (lateral) position and the (left) sacral decubitus was exposed. It had black tissue and was foul smelling. We opened up the skin and noted the dead tissue that was debrided. It was full thickness skin, subq (subcutaneous), fascia, and muscle ..." The (Hospital) Wound Culture Report dated 6/5/12 documented, "... Heavy growth Escherichia coli ..." v. On 6/6/12 at 3:40 p.m. the DON was interviewed regarding Resident #6: 1) The DON was asked, "Were you aware of the wound decline on 5/1/12?" The DON stated, "I'm not sure when I knew. We get a weekly wound log report." The DON left the room to get the weekly wound reports and returned at 3:47 p.m. The DON stated, "What I've got shows (Resident #6) only had a Stage 2 pressure ulcer for the entire she was here." The "Weekly/Monthly Wound Log" form dated May 2012 documented: "(Resident # ,6) ... Wound Type: (Pressure); Date first observed: 4/26/12; Location: (Left) buttock; Week 1: 5/1/12; Current Stage 2; Healing: No; Size: 17.2 x 8.0 x 0.1 ... Week 2: 5/8/12; Current Stage 2; Healing: Yes; Size: 14.5 x 11.2 x 0.1 ... Week 3: 5/14/12; Current Stage 2; Healing: Yes; Size: 14.0 x 7.5 x 0.1 ... Week 4: 5/21/12; Current Stage 2; Healing: Yes; Size: 14.0 x 7.5 x 0.1 ... Week 5: 5/28/12; Current Stage 2; Healing: Yes; Size: 12.0 x 4.5 x 1.5 ... " 2) The DON was asked, "Did you know about the wound drainage and change in the wound, eschar and slough on 5/1/12?" The DON stated, "No, the wound report didn't document any drainage." 3) The DON was asked, "What is a pressure redistribution surface?" The DON stated, "It's a fancy name for a Geo mattress." The DON was asked, "What kind of mattress is (Resident #6) on?" The DON, Nurse Consultant #1, and this surveyor went to the resident's room to check the mattress. The mattress on the resident's bed was a Lumex series 419 mattress. On 6/5/12 at 3:45 p.m. there was no low air loss mattress on the resident's bed. The mattress was labeled Lumex 419 series. The manufacturer's specifications for Lumex Gold Care Foam Mattress 419 Series documented, "... Effective for the prevention and treatment of [REDACTED]. 4) The DON was asked, "What was documented on the weekly wound report for the stage of the left buttock pressure ulcer?" The DON stated, "Two." The DON was asked, "When were you aware of (Resident #6's) wound drainage?" The DON stated, "Sunday (6/3/12) afternoon. The nurse (LPN #2) informed me she had gotten a culture without talking with the doctor, so she marked the order out and called the APN who ordered wound clinic ASAP (as soon as possible)." The DON was asked, "Did anyone ever report any drainage to you prior to this?" The DON stated, "No." The DON was asked, "Who reviewed the hospital records, History and Physical and Discharge instructions prior to accepting (Resident #6)?" The DON stated, "Myself." The DON was asked, "Did you note the condition of the wound, 'Sacral area surrounding remains non-blanchable and may represent deeper tissue damage' and need for low air loss mattress?'" The DON stated, "No, I stopped at [MEDICATION NAME]. I wrote the admit orders. I didn't read that far." w. On 6/6/12 at 4:45 p.m. the APN was asked, "Did you know (Resident #6) had wound drainage since 5/1/12 that was described as purulent, moderate to large amounts?" The APN stated, "No, not significantly. I knew it was draining and it wasn't getting better. I didn't really know about drainage until this weekend (6/2/12 - 6/3/12) when they called me and I told them I'd look at it on Monday (6/4/12) and see if she needed an antibiotic." x. On 6/6/12 at 5:32 p.m. LPN #3, the 3:00 p.m. to 11:00 p.m. charge nurse for Resident #6, was asked, "Did (Resident #6) have any wounds?" LPN #3 stated, "Yes, when she came the whole buttock area, when she left it was the left butt cheek." LPN #3 was asked, "Did (Resident #6) have any drainage from the wound?" LPN #3 stated, "The dressing was changed at least daily or more often because of the drainage." LPN #3 was asked, "What did the drainage look like?" LPN #3 stated, "Yellow." On 6/6/12 at 7:55 a.m. LPN #4, charge nurse for 11:00 p.m. to 7:00 a.m., was asked, "Did (Resident #6) have a dressing on her wound?" LPN # 4 stated, "I think she did." LPN #4 was asked, "Any odors from the dressing or wound?" LPN #4 stated, "Sometimes she did, it was a little bit foul smelling." LPN #4 was asked, "When did you notice the odor?" LPN #4 stated, "About 1 week (5/28/12 to 6/4/12) before she left." On 6/6/12 at 8:10 a.m. CNA #5 stated, she worked 11:00 p.m. to 7:00 a.m., mostly on (Resident #6's) hall. CNA #5 was asked, "Did (Resident #6) have a dressing?" CNA #5 stated, "Yes." CNA #5 was asked, "Where?" CNA #5 stated, "Coccyx." CNA #5 was asked, "Did you ever see any drainage on the dressing?" CNA #5 stated, "Yes and we'd ask the nurse to change it." CNA #5 was asked, "Did the drainage come through the dressing?" CNA #5 stated, "Yes, sometimes it would saturate the dressing and get on the sheets." CNA #5 was asked,, "What was the drainage like?" CNA #5 stated, "Thin, oozy, slime. It looked like snot. It was clear mostly, sometimes yellow, green." CNA #5 was asked, "Any odor?" CNA #5 stated, "Yes, it was horrible." CNA #5 stated she'd noticed the odor with the drainage for about 1 month. On 6/7/12 at 8:30 a.m. LPN # 1, the charge nurse for Resident #6 on the 7:00 a.m. to 3:00 p.m. shift, was asked, "Did (Resident #6) have a dressing?" LPN #1 stated, "Yes." LPN #1 was asked, "Where?" LPN #1 stated,"One on every buttock on admit. One healed, then just one on the left buttock." LPN #1 was asked, "Was there a lot of drainage from the left buttock?" LPN #1 stated, "Yes, she did." LPN #1 was asked, "Who changed the dressing?" LPN #1 stated, "The Treatment Nurse, me and the evening shift." LPN #1 was asked, "Were the dressing changes done for the drainage?" LPN #1 stated, "Primarily due to drainage. It would get wet with drainage and fall off or (Resident #6) would pull it off." LPN #1 was asked, "How often was it changed due to drainage?" LPN #1 stated, "I changed it two times due to showers, two times due to resident pulling it off and every time it got saturated and would not stick." LPN #1 was asked, "Did you document every dressing change?" LPN #1 reviewed the Treatment Administration Record (TAR) and nurses notes. LPN #1 highlighted 3 dressing changes he'd done on the TAR (Treatment Administration Record). LPN #1 stated, "Not all of them." LPN #1 was asked, "Any odor to the drainage or wound?" LPN #1 stated, "Yes, not bad, but it was obvious it was abscessed." LPN #1 was asked, "Did you notify the physician or APN of the drainage or abscess?" LPN #1 stated, "Not personally. I left that to the wound care nurse. When the APN came in I'd tell her we are doing this or that and it looked bad. The last week before she was sent to the hospital the wound care nurse and I would talk every morning about the wound." LPN #1 was asked, "Did you call the physician the week before she was hospitalized ?" LPN #1 stated, "I did not." LPN #1 was asked, "Did you ever notify the APN or physician about the drainage?" LPN #1 stated, "I know I didn't." LPN #1 was asked,, "Did you tell the physician or APN about the odor?" LPN #1 stated, "I don't recall." LPN #1 was asked, "Did you ever ask the APN for an order to culture the drainage?" LPN #1 stated, "I did not." LPN #1 was asked, "If a resident has drainage, would you think you should ask for an order to culture the wound?" LPN #1 stated, "Yes." y. On 6/7/12 at 11:30 a.m., Resident #6's attending physician and the Medical Director was asked, "Were you informed of worsening of decubitus with drainage since 5/1/12 for (Resident #6)?" The attending physician stated, "No, I was not informed of any problems. They may have talked with (APN) but no one notified me."