Every finding on record at Lakeside Rehabilitation and Care Center

Based on record reviews, interviews, and policy review, the facility failed to develop the comprehensive care plan to include the use of an indwelling urinary catheter for one of 21 sampled residents (Resident (R)7) and include extreme pain with movement or touch for one of 21 sampled residents (R74) reviewed for care planning. This had the potential for the residents not to be monitored for an indwelling catheter, pain, and have unmet care needs. Findings include:1.Review of R7's electronic medical record (EMR) located under the MDS tab revealed the 5-Day Minimum Data Set (MDS) with Assessment Reference Date (ARD) 07/25/24 revealed an admission date of 07/18/25 and a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating cognitively intact. R7's diagnosis included benign prostatic hyperplasia without lower uropathy and that R7 has an indwelling urinary catheterReview of R7's EMR Care Plan under the Care Plan tab revealed that the care plan did not indicate R7 has a foley catheter.Review of the facility's policy titled Comprehensive Person-Centered Care Planning revised 4/2025 stated, It is the policy of this facility that the interdisciplinary team (lDT) shall develop a comprehensive person-centered care plan for each resident that includes residents' needs identified in the comprehensive assessment.During an interview on 08/27/25 the Registered Nurse Supervisor (RNS) stated that R7's care plan did not include the use of the indwelling urinary catheter and that it absolutely should be included in the care plan. The RNS also stated that the care plan is to provide staff information related to the care for R7's indwelling urinary catheter.During an interview on 08/27/25 at 3:45PM, the Director of Nursing (DON) stated the indwelling urinary catheter should be included on R7's care plan because it's a snapshot of his care.During an interview on 08/27/25 at 4:10PM, the Infection Preventionist (IP) stated that the indwelling urinary catheter could not be located on the care plan. The IP confirmed that R7 does have an indwelling urinary catheter, and it should be care planned so that staff know how to provide the proper care.2.Review of R74's admission Record located under the Profile tab in the EMR revealed the resident was initially admitted on [DATE] with the most recent re-admission [DATE]. R74 had diagnoses that included functional quadriplegia; multiple sclerosis; polyneuropathy; contracture of muscle, multiple sites; and abnormal posture.Review of the quarterly MDS located under the MDS tab in the EMR revealed a BIMS score of 15 out of 15 which indicated R74 was cognitively intact.During an interview on 08/25/25 at 12:26 PM, R74 stated, I try to get out of bed once a day and on the weekends when my family visits. I don't like to be moved. R74 stated that he is always in pain, receives pain medications and that touch or movement sets off spasms that he cannot release.Review of the most recent Physician Orders located under the Orders tab in the EMR dated August 2025 noted R74 was receiving treatment for a stage III pressure ulcer on his right buttock, skin tears to his mid back, and a pressure ulcer on the right posterior ear. Review of the Progress Notes dated 07/23/25 located under the Progress Notes tab in the EMR revealed a notation by the Nurse Practitioner (NP) that read, Nurse is concerned of pain control, patient states it is better now that he has more muscle relaxers.Review of the most current Comprehensive Care Plan located under the Care Plan tab in the EMR dated 05/29/25 had revisions related to the resident's pressure ulcers dated 07/17/25, 07/21/25, 07/29/25, and 08/22/25. A focus was noted to identify the resident's potential for skin impairment and pressure ulcer development with an intervention, turn and reposition q (every) 2-3 hrs (hours) as resident allows. The care plan did not identify R74's pain upon touch which was reported to cause spasms or how to accomplish repositioning in the least painful manner. During an interview on 08/25/25 at 12:56 PM, Licensed Practical Nurse (LPN2) said R74 did not like to be repositioned because it caused him pain. During an interview on 08/28/25 at 8:23 AM, LPN3 stated, He often refuses to be repositioned because of the pain it causes him.During an interview on 08/28/25 1:35 PM, the Assistant Director of Nurses (ADON) stated, He (R74) has very bad chronic pain and we try to reposition him, but he refuses. When he is touched, the spasms set off, and it's extremely painful for him. When asked why the specific information about R74's significant pain with touch, movement, and spasms was not on his care plan, the ADON stated, The care plan system did not transfer over after the acquisition of the facility [06/01/25]. We're still working on it.During an interview on 08/28/25 at 4:00 PM, the DON confirmed that the care plan did not have specifics about R74's pain or how to position resident to prevent him from experiencing pain. The DON stated, I know we should have had that on his care plan.

Based on interviews, record review, and review of the facility's policy, the facility failed to ensure one resident (Resident (R) 28) was free from significant medication errors out of a total sample of 21 residents. The facility administered insulin to R28 when his blood sugar level was below the identified range to administer the insulin. The medication error had the potential to cause the resident to become hypoglycemic (abnormal decrease of sugar in the blood).Findings include:Review of R28's admission Record located under the Profile tab in the electronic medical record (EMR) revealed R28 was admitted on [DATE] and had diagnoses that included type 2 diabetes mellitus with diabetic neuropathy.Review of the most recent Physician Orders located under the Orders tab in the EMR dated August 2025 revealed an order for Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 8 unit subcutaneously before meals related to TYPE 2 DIABETES MELLITUS WITH OTHER SPECIFIED COMPLICATION.Hold if under 150. Notify physician if CBG [Capillary Blood Glucose] results are less than 70 or more than 360.Review of the Medication Administration Records (MARs) dated June 2025, July 2025, and August 2025 revealed the following dates where insulin was recorded as given with a blood sugar (BS) level below 150:JUNE 2025:06/01/25 BS 134 at 7:30 AM06/03/25 BS 148 at 11:30 AM06/03/25 BS 133 at 4:30 PM06/04/25 BS 119 at 7:30 AM06/08/25 BS 128 at 7:30 AM06/12/25 BS 148 at 7:30 AM06/14/25 BS 118 at 4:30 PM06/15/25 BS 149 at 4:30 PM06/19/25 BS 107 at 4:30 PM06/26/25 BS 131 at 7:30 AM06/29/25 BS 142 at 7:30 AM06/30/25 BS 122 at 7:30 AMJULY 2025:07/03/25 BS 128 at 7:30 AM07/04/25 BS 113 at 7:30 AM07/15/25 BS 116 at 7:30 AM07/15/25 BS 88 at 4:30 PM07/16/25 BS 140 at 7:30 AM07/18/25 BS 117 at 4:30 PM07/20/25 BS 125 at 7:30 AM07/22/25 BS 139 at 4:30 PM07/29/25 BS 96 at 7:30 AM07/30/25 BS 107 at 7:30 AM07/30/25 BS 138 at 4:40 PMAUGUST 2025:08/03/25 BS 86 at 4:30 PM08/04/25 BS 110 at 7:30 AM08/13/25 BS 130 at 11:30 AM08/14/25 BS 111 at 7:30 AMReview of the only Incident Report completed for the medication errors dated 07/20/25 provided by the Director of Nurses (DON) read, Went to give patient his am [morning] insulin and check bs and found lhat [that] bs was wnl [within normal limit] at 125, did not see that bs needed to be over 150 in order to receive the short acting order, pt [patient] noticed after I had that it was under 150, after clarifying the order, called the on call provider and updated, order receive snack. Later bs was elevated, and short acting given as ordered.Review of R28's June, July, and August 2025 Progress Notes located in the EMR under the Progress Notes tab indicated no adverse effects of the medication errors were documented.During an interview on 08/27/25 at 11:00 AM, R28 denied knowledge of medication errors involving his prescribed medications. R28 stated, As far as I know, I get what I'm supposed to.During an interview on 08/28/25 at 8:30 AM, Licensed Practical Nurse (LPN3), responsible for many of the medication errors, said she did not realize the errors.During an interview on 08/28/25 at 8:50 AM, Registered Nurse (RN1) responsible for the 07/20/25 medication error stated, I think we missed the order because of the way it's written.During an interview on 08/28/25 at 4:00 PM, the DON said she was not aware of R28's medication errors. When asked if the facility had investigated any other medication errors following the 07/20/25 incident, the DON said, No.Review of the facility's policy titled Administration of Medication dated 06/25 revealed, Medications must be administered in accordance with the written orders of the attending physician as indicated on the eMAR [electronic medication administration record].

Based on observation, record review, policy review, review of the State Survey Long-Term Care Reporting Portal and interviews, it was determined the facility failed to ensure residents were free from abuse and neglect. This was true for 6 of 8 residents (#4, #18, #20, 26, 46 and #56) reviewed for abuse and neglect. These deficient practices resulted in residents being subjected to neglect, abuse, and ongoing verbal abuse with the potential for physical and/or psychosocial harm. Findings include: -Residents #4, #20, #26, and #46 experienced mental and psychosocial harm when they were verbally abused by Resident #61. - Resident #56 experienced neglect when she did not receive wound care for a pressure ulcer. - Resident #18 experience physical harm from the facility staff during cares. The facility's Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property Policy, dated 8/22, stated a resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy defined verbal and mental abuse as oral, written, or gestured language that includes disparaging and derogatory terms to the resident or their families or within their hearing distance regardless of their age, ability to comprehend or disability, that would demean or humiliate, resulting in pain or mental anguish. Mental abuse can be verbal or non-verbal. It includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. 1. Facility and resident records documented multiple incidents of Resident #61's verbal abuse of Residents #4, #20, #26, and #46, and incidents of verbal and physical aggression which residents witnessed resulting in mental and psychosocial harm, as follows: - Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and chronic hypertensive kidney disease. A quarterly MDS assessment dated [DATE] documented Resident #4 was cognitively intact. - Resident #20 was admitted to the facility on [DATE] with multiple diagnoses including multiple sclerosis, Todd's paralysis, aphasia, and mixed receptive-expressive language disorder. A quarterly MDS assessment dated [DATE], documented Resident #20 was severely cognitively impaired. - Resident #26 was admitted to the facility on [DATE] with multiple diagnoses including anemia, fracture of the femur, osteoporosis, and unspecified dementia. An Annual MDS assessment, updated 8/14/24, documented Resident #26 was severely cognitively impaired. - Resident #46 was admitted to the facility on [DATE] with multiple diagnoses including acute and chronic respiratory failure with hypoxia, pulmonary embolism, diabetes, and congestive heart failure. A Quarterly MDS assessment, dated 7/9/24, documented Resident #46 was cognitively intact. a. An I&A report dated 8/12/24, documented Resident #61 became agitated, he yelled and cursed at Resident #20. Resident #26 witnessed this and told Resident #61 he needed to stop yelling and cursing at Resident #20. Resident #61 then began yelling at Resident #26. A physician's assessment, dated 8/14/24, recommended that referrals be made for Resident #61 to an autism specialist for evaluation and to a neurologist or geriatric specialist for further evaluation for management of Resident #61's dementia. No documentation was found in Resident #61's records that he was referred to an autism specialist, a neurologist or geriatric specialist. A nursing progress note for Resident #61, dated 8/17/24, documented Resident #61 was yelling outside of Resident #4's room and was verbally aggressive towards Resident #26, cussing and yelling at her. Resident #34 walked by and told Resident #61 to stop talking to her like that. Resident #61 and Resident #34 began yelling and cussing at each other before being separated by staff. An I&A report, dated 8/17/24, documented Resident #34 left the nurses office because Resident #61 was yelling indiscriminately [at Resident #26] and was speaking aggressively, so Resident #34 told Resident #61 to stop speaking to people that way. Resident #34 stated, Resident #61 then became aggressive towards him, spitting in his face, saying the F-word and F-your family repeatedly using the F-word and putting his middle finger in Resident #34's face. Resident #34 returned to his room, called the police, and made a report. The report documented the facility could not identify why Resident #61 was verbally aggressive towards Resident #26. Resident #61 was moved to a different hall with police assistance. Seventeen residents were assessed if they felt safe in the facility and if they were fearful of any residents. Resident #3, #20, #26, and #30 stated they were fearful of Resident #61. The report further documented Resident #61 was moved to another room. The report concluded Resident #61 has many triggers which influence his aggression and behaviors, directly related to his Autism and OCD diagnoses. The facility is working to place Resident #61 in a different environment as he would benefit from placement in a smaller setting that manages behaviors. The facility did educate staff on Resident #61's triggers, and indicated they would update his care plan as new triggers were identified. A Social Services progress note, dated 8/23/24 at 5:36 PM, documented a new unidentified resident in the facility (stated she was fearful of Resident #61 because he kept coming into her room and he had threatened her. The resident reported Resident #61 yelled and cursed at her several times, and that Resident #61 was angry at her because she was staying in his previous room. The resident told the SSD that if she was not able to move to a different area of the building, she would have her daughter take her home. The resident reported she has called her daughter several times and told her daughter she did not feel safe in the facility. Grievances reviewed for August 2024 did not show documentation of this interview. No I&A report was found regarding this incident. A nursing progress note for Resident #61, dated 9/7/24 at 3:19 PM, documented Resident #61 was standing over Resident #26 who was sitting in her wheelchair in the entrance of her room. Resident #61 screamed and yelled profanity to Resident #26. When asked, Resident #61 stated Resident #26 told him to stop entering her room. An I&A report dated 9/7/24, documented Resident #26 stopped Resident #61 from entering her room, stating, Why are you entering my room, do not come into my room. Resident #61 then yelled and screamed at Resident # 26, Fuck you lady, go fuck yourself, who the fuck to you think you are? It stated Resident #26 has poor short-term memory and does not remember the previous incidents with Resident #61. The report concluded Resident #26 will redirect or scold Resident #61 when he raises his voice, triggering Resident #61's negative responses to her. As Resident #26 does not remember the interaction, she did not show signs or symptoms of psychosocial harm. A SBAR note, dated 9/13/24 at 4:20 PM, documented a nurse reported Resident #61 had frequent outburst of cursing and yelling at residents and staff. The note documented, Today Resident #61 stated I am going to slit all of your cock sucking mother fucking throat, I am going to take a knife and slit all your throats. I am going to just shoot this mother fucking place up and kill y all. The SBAR documented Resident #61's primary provider recommended Resident #61 be sent to the ER for psych evaluation and should not return to the facility at this time. A hospital progress note for Resident #61, dated 9/13/24, documented, The staff at the facility where [Resident #61] resides has said [Resident #61's] behavior has been escalating and he becomes loud and makes threats and frightens the other residents. [Resident #61] has not been physically aggressive. However, due to the nature of his [Resident #61's] statements that he was going to kill kitchen staff [Resident #61] will not be accepted back to the facility at this point. Resident #61 was diagnosed to have aggressive behavior due to dementia. b. Facility residents were interviewed about abuse and neglect, as follows: During an interview on 10/08/24 at 11:39 AM, Resident #4 was asked if she felt safe in the facility, and if the staff and residents were treating her well. She stated, I don't feel safe with [Resident #61]. He came into my room, yelling at me, and I spoke back to him. He left. I see him around the facility, and I don't make eye contact. I look down or towards the wall. During an interview on 10/08/24 at 10:23 AM, Resident #46 was asked about if she felt safe in the facility, and if the staff and residents were treating her well. She stated, Resident #61 used to live across the hall from me and would wander into my room. I didn't feel safe. I know he doesn't like women. They moved him, and it's been better, but I still don't know if I should fear him as I can't move, and [staff] don't come very quickly when I press the call light. I also think about what I have nearby to pick up and defend myself if he does come back. c. A Resident Council Meeting was conducted on 10/8/24 at 2:30 PM. During the Resident Council meeting Resident's #4, #17, #18, #25, #30, #34, #36, and #49 voiced concerns regarding Resident #61, as follows: All eight residents in attendance stated Resident #61 makes their life in the facility uncomfortable and were fearful of him. When asked if they felt safe in the facility, all residents at the Resident Council Meeting listed above, turned their head to the surveyor, with large eyes and expressions of fear shaking their head and stating out loud, NO! The residents in attendance stated Resident #61 made them feel as they needed to adjust their behavior to include looking down and away if they were passing him in the hallway. Resident #17 and #34 stated they felt the need to step in between female staff or residents to keep everyone safe. Resident #34 stated he was unhappy calling the police didn't get a respectful response as the facility is labeled the [name of the facility] loonies. During an interview on 10/11/24 at 1:31 PM, with the Administrator, he was asked what the facility was doing regarding the behavior of Resident #61 and ensuring the safety of the facility residents. The Administrator stated, We have had to send Resident #61 to the hospital to get psych evaluations. No one was available to see him here as our facility is not set up for these types of evaluations. The Administrator stated the facility had been working to get Resident #61 placed into an appropriate facility to care for his specific diagnoses. Staff have been educated on Resident #61's specific triggers, and how to redirect him. 2. Physical abuse by CNA #2 directed at Resident #20: An I&A report dated 3/17/24, documented CNA #2 swatted Resident #20's bottom. CNA #2 was terminated. The I&A documented CNA #2's background check was not completed prior to her working in the facility. On 10/10/24 at 10:04 AM, the Administrator stated background checks are received prior to placing employees on the floor with the residents. On 10/11/24 at 2:30 PM, the Administrator clarified the facility uses a service which provide preliminary approval based on background check that does not include fingerprinting. Finger printing must be completed within the first month. CNA #2 had not been working at the facility long enough to get her fingerprints taken or assessed before she was terminated. On 10/11/24 at 11:54 AM, the DON stated she has been employed for two weeks and she was not familiar with this complaint. She will be looking into the case to see what happened. The DON stated, in her experience, nursing staff are not allowed to work with residents without having a clear background check prior to employment. 43353 3. Resident #56 did not receive wound treatment for her pressure ulcer. Resident #56 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease. The resident was on Hospice care upon admission and discharged to a Hospice Facility on 09/17/24. Review of Resident #56's admission MDS dated [DATE], documented Resident #56 was cognitively intact. Review of Resident #56's Health Status Note dated 08/25/24 documented Resident had approximately a five-centimeter (cm) diameter, non-blanchable pressure ulcer with multiple two-millimeter openings on her coccyx area. A staff member from the Hospice agency stated that she was sending a nurse to assess the resident's coccyx area for an air mattress. Review of Resident #56's record did not include an order for treatment of her wound. Also Resident also did not include a care plan for her wound. During an interview on 10/10/24 at 2:52 PM, the ADON stated, Resident #56's did have a wound and [the facility's] our wound care physician was not following her care. She said the resident was a hospice patient, and they were responsible for providing wound care orders and treatments. She confirmed there were no orders, skin assessments, or a care plan for Resident #56, or one from the Hospice Agency. During an interview on 10/10/24 at 2:53 PM, the Administrator stated, I didn't know what occurred regarding this resident until last week, when the daughter came in to pick up her belongings after she passed away at the hospice house. Yes, we are still the primary caregivers, but they took care of the wound. Ultimately her daily care is our responsibility. Their hospice doctor writes their orders for their patients. The service agreement we have with Hospice of North Idaho transferred over with the sale of the building. I have reached out to them for an /updated agreement. During an interview on 10/11/24 at 1:30 PM, the DON stated, If the resident is admitted to this facility, then we are the primary caregivers and responsible for them. I don't know why or how this occurred since I only arrived last week. However, since learning about this resident, I met with the RN of our current hospice resident, and we have come to an agreement that she must see myself or the unit manager prior to leaving so that we can coordinate care and we're always on the same page. The DON confirmed there was no collaboration with the Hospice Agency that was providing care to Resident #56 while she was a resident at the facility. She said she only knew the Hospice nurse came weekly to see the resident. She further said, this shouldn't have happened and won't happen again. Review of Service Agreement between Hospice of [name of hospice agency] and [name of facility] signed 06/10/19 revealed: 4.2 Facility Services: a) The Facility will comply with all applicable state and/or federal regulations when providing care to residents who have elected Hospice. Basic services will include the following . iii) Nursing services as required by Idaho Department of Health and Welfare Rules, IDAPA 16, Title 03, Chapter 02, Rules and Minimum Standards for Skilled Nursing and Intermediate Care Facilities . vi) Supervision of Facility staff providing services under the Hospice Plan of Care established by the Hospice team . vii) Services provided will be consistent with the services provided to the resident before hospice care . b) Ensure that each Hospice resident receives treatments, medications and diet as prescribed, and is kept clean, comfortable and well groomed . e) Allow, members of the IDT, as identified in the Plan of Care to attend, counsel, treat and serve Hospice residents . k) Except as otherwise provided herein, the services of the facility provided pursuant to the terms of this Agreement shall be made available to hospice residents 24 hours a day, 7 days a week. During this term or any succeeding terms of this Agreement, the Facility will hold itself (including a sufficient number of its personnel, as determined by the Facility and the Hospice as having the requisite skills) available to finish, and shall furnish the services and facilities contracted for herein. 36193 4. Physical abuse directed by Resident #130 to Resident #18. Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including left hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following stroke and diabetes. a. A review of an investigative summary report uploaded to the State's Long-Term Care Reporting Portal, dated 5/28/24, documented [Resident #18] reported to a staff that [Resident #130] tried to block her from going out to the smoking area. She stated [Resident #130]would not move, and they had an argument. [Resident #18] stated [Resident #130] reached over and slaped her to each side of her face. The investigation report documented [Resident #18] was noted to have a scratch, approximately 6.2 x 0.4 on the left side of her face. There was also one small superficial open area at the top of the scratch closer to her ear. [Resident #130 was interviewed and stated [Resident #18] was blocking the exit to the smoking area and had an argument. [Resident #130] stated she pushed [Resident #18's] wheelchair out of the way but did not touch any part of [Resident #18]. The investigation report documented [Resident #130] had a large brace on her hand and wrist that could have easily caused a scratch if there was contact made with [Resident #18's] face. Activities and nursing staff were interviewed and all report stated that prior to the incident [Resident #18] did not have a scratch on her face. The facility's investigation report concluded that it was suspected [Resident #130] slapped [Resident #18]. The report documented the facility had taken measures to ensure that contact between the two residents was limited and any activities would be supervised by staff. Both residents agreed to a set schedule for smoking. [Resident #18] would smoke during the even hours and [Resident #130] would smoke during the odd hours. On 10/11/24 at 11:43 AM, the Administrator together with the ADON stated he was the facility's abuse coordinator and stated all suspected residents' abuse/neglect are to be reported and investigated. The ADON stated Resident #130 denied slapping Resident #18, but later on she acknowledged that she did slap Resident #18. The ADON stated the two residents were put on different smoking schedules. 5. Physical abuse by CNA #3 directred at Resident #18. A review of an investigative summary report uploaded to the State's Long-Term Care Reporting Portal, dated 2/27/24, documented [Resident #18] was fearful of a CNA #3. [Resident #18] was interviewed on 2/26/24, [Resident #18] stated a staff came to wake her up and pushed her bad hip. She reported the staff seemed upset that she had diarrhea and needed to be cleaned up. [Resident #18] stated CNA #3 told her if she could go out to smoke, she could get up to go to the bathroom. [Resident #18] reported CNA #3 grabbed her right wrist and left ankle and flipped her onto her back forcefully. She stated CNA #3 was very angry and aggressive towards her. [Resident #18] stated she asked CNA #3 to stop and to leave her alone multiple times but, CNA #3 did not stop holding her down. [Resident #18] complained of right wrist injury from the incident. She was found to have 3.5 cm x 3.5 cm reddened area on the top surface of her wrist. On the palm side of her wrist were three small circular bruises each measuring 1.25 cm x 1.5 cm. [Resident #18] stated she was afraid of CNA #3 and does not want her to ever take care of her or be near her. The facility's investigation report concluded the allegation of abuse by CNA #3 to [Resident #18] was substantiated due to the presence of physical bruising and redness on her wrist which were not present prior to the cares provided by CNA #3. The facility's investigation report, documented CNA #3 was terminated from her employment via phone conversation on 2/26/24 at 12:34 PM. On 10/11/24 at 11:48 AM, the Administrator stated because of the bruises sustained by Resident #18 during cares, CNA #3 was terminated from her employment. The Administrator also stated the facility had a float pool of staff and hire them at corporate level with long-term contracts, usually 13 weeks, to better care for the residents.

Based on record review, review of the State Long-Term Care Reporting Portal, I&As, review of facility policies and procedure, and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This was true for 4 of 4 residents (#3, #126, #127 and #129) reviewed for medication administration. Resident #129 was harmed when he experienced dizziness and low blood pressure and needed to be sent to the hospital due to his hypotension. Findings include: The facility's Medication Administration procedure, undated, directed the licensed nurse to check the following to administer the medication: - Right medication - Right dose - Right dosage form - Right route - Right resident - Right time 1. Resident #129 was admitted to the facility on [DATE], with multiple diagnoses including heart failure, hypertension, and atrial fibrillation (irregular heartbeat). A facility Investigative Summary Report, dated 8/13/24 at 11:00 AM, documented Resident #129 took a cup of pills which was intended for another resident. Resident #129 complained of being dizzy, his blood pressure was taken, and it was 74/38. The provider was notified, and an order was received to send Resident #129 to the hospital. Resident #129 was informed the provider wanted him to go to the hospital for evaluation but, Resident #129 did not want to go to the hospital and stated he felt like he would be fine. When his chair was sat-up from a tilt position, Resident #19 was getting dizzy again. After 5-10 seconds Resident #129 head fell to his chest, his eyes rolled back, and his tongue fell out of his mouth. The nurse tried sternal rubbing to arouse him,and he did not respond. Resident #19 was laid down back in chair. After five seconds, Resident #129 came to and asked what happened. He was told that he crashed and would be sent to the hospital. Resident #129's blood pressure at this time was 80/42 mmHg. EMS was called and Resident #142 was taken to the hospital. The Investigative Summary Report, documented Resident #129 was wrongly administered the following medications by the float nurse at 11:00 AM on 8/13/24: - ASA 81 mg - irbesartan (anti-hypertensive) 75 mg (milligram) - Pantoprazole (decreases the amount of acid produced in the stomach) 20 mg - Metformin (anti-diabetic)500 mg - Senna Plus (laxative) 8.6-50 mg A Hospital progress note, dated 8/13/24, documented Resident #129 received irbesartan 75 mg which was prescribed for another resident, and he would be admitted due to persistent hypotension (low blood pressure). On 10/10/24, the DON who just started in the facility two weeks prior, reviewed the Investigative Summary report and stated the float nurse did not follow the six rights of medication administration. The DON stated the nurse should make sure the right medications were administered to the right resident. 2. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and hypertension. A I&A report, dated 2/29/24, documented Resident #3's blood sugar was not checked and did not receive her 6 units of Novolog. An interview with the day shift nurse stated she was very busy and did not have time to complete the blood sugar check or give insulin. When asked why she did not ask for assistance from RCM or another nurse, the day shift nurse stated, I was too busy. The I&A documented the day shift nurse did not complete an incident report, nor did she return to work her next shift. The day shift nurse was subsequently terminated on 3/4/24. On 10/10/24 at 1:30 PM, the DON who just started in the facility two weeks prior, reviewed the I&A and stated the nurse should have checked Resident #3's blood sugar if it's supposed to be done during her shift and administered the medication as ordered by the physician. The DON also stated nurses on the floor should have asked the RCM for assistance as needed. 3. Resident #125 was admitted to the facility on [DATE], with multiple diagnoses including anoxic (a complete loss of oxygen supply in your body or brain) brain damage and persistent vegetative state. An I&A report, dated 4/24/24, documented Resident #125 was administered Norco (opioid pain medication) 5/325 mg and Clonazepam (antianxiety) 0.5 mg via is PEG tube at 5:00 PM from the day shift nurse, and received the same medications again at 6:00 PM from the evening shift nurse. Resident #125 was monitored and no changes in condition was noted. The I&A documented the nurse who administered the second medications was a travel agency contract nurse and was educated on the process for checking out all medications on the MAR to ensure they are not given too soon and how to look for the last dose given on the MAR. On 10/10/24 at 1:45 PM, the DON who just started in the facility two weeks prior, reviewed the I&A and stated the medication error was committed by the travel nurse and was educated on the importance of medication administration. The DON also stated the facility is now contracting nurses on a long-term basis so they have time to get to know the facility as well as the residents. 4. Resident #127 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including respiratory failure, diabetes, and liver cirrhosis (severe scarring of the liver that can be caused by many diseases and conditions, such as hepatitis or alcoholism). An I&A report, dated 7/7/24, documented Resident #127 did not receive his Novolog sliding scale prior to his lunch. The report documented the 6:00 AM to 12:00 PM nurse told the oncoming nurse that she had not given the insulin to the residents requiring sliding scale insulin on the 500 Hall. The oncoming nurse stated she thought the 6:00 AM to 12:00 PM nurse told her all insulins were given. Both nurses were educated on the requirements for shift-to-shift hand over of residents' medications. Resident #127's blood sugar was monitored, no signs and symptoms of hypoglycemia or hyperglycemia noted. On 10/10/24 at 1:55 PM, the DON who just started in the facility two weeks prior, reviewed the I&A report and stated Resident #127 did not receive his sliding scale insulin due to miscommunication between the two nurses. The DON stated 6:00 AM to 12:00 PM nurse should have stayed to complete the medication administration or wrote down the name of residents she was unable to give the sliding scale of insulin for the oncoming nurse.

Based on observation and staff interview, it was determined the facility failed to ensure the kitchen equipment and environment was maintained, clean, and food was stored in a safe and sanitary manner. These deficiencies had the potential to affect the 69 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: FDA Food Code Section 3-303.12 documented packaged food may not be stored in direct contact with ice or water if the food is subject to the entry of water because of the nature of its packaging, wrapping, or container or its positioning in the ice or water. The FDA Food Code Section 6-501.12 Cleaning, Frequency and Restrictions, documented cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when foods are in protected storage and when food is not being served or prepared. 1. The initial kitchen inspection was conducted on 10/7/24 at 11:45 AM, with the CDM (Certified Dietary Manager). The following was observed - Condensation icicles from the cooling fans in the walk-in freezer were observed falling and accumulating on the following food items located below the cooling fans: cardboard boxes of frozen vegetables. - An accumulation of ice about 2.5 inches thick, was around the pipe behind the condenser above the cardboard boxes of vegetables. 2. A second kitchen inspection was conducted on 10/10/24 at 3:15 PM with the CDM. The following was observed: - Condensation icicles from the cooling fans in the walk-in freezer were observed falling and accumulating on the following food items located below the cooling fans: cardboard boxes of frozen vegetables, opened packages of frozen hamburgers. - An accumulation of ice about 2.5 inches thick, was around the pipe behind the condenser above the cardboard boxes of vegetables. On 10/10/24 at 3:20 PM, CDM stated that facility maintenance is responsible for cleaning the refrigerators and walk-in freezers. She stated she was not sure when the pipe behind the condenser was last looked at, but it had been during this past summer. The CDM also stated that a drip pan is usually below the condenser to catch any water droplets that fall. She was not sure why the drip pan was not there but acknowledged the food below the ice droplets had been contaminated. On 10/11/24 at 10:30 AM, the Maintenance Director confirmed that a deep cleaning of the refrigerator and walk-in freezer had been completed over the summer. However, it was the responsibility of the kitchen staff to spot clean in between, especially if there is ice build-up. The Maintenance Director confirmed the pipe behind the condenser should be fixed as the ice build-up on the pipe was not the kitchen staff's responsibility. On 10/11/24 at 2:33 PM, the CDM provided a kitchen cleaning schedule documenting daily breakdown of staff responsibilities to include cleaning the interior of the refrigerator and walk-in freezer. She could not explain why there had been a large buildup of ice in the walk-in refrigerator.

Based on observation, interview, review of facility policy, and review of facility training document, the facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) for one of three residents (Resident #173) observed for enhanced barrier precautions (EBP) when providing care out of a total sample of 32 residents. This had the potential for the resident to have an increase for infection. Findings include: Review of Resident #173's Admission Record in the Profile tab of the electronic medical record (EMR) revealed an admitted [DATE]. The Admission Record revealed a diagnosis of malignant neoplasm (cancer) of endometrium (tissue of the uterus). Review of Resident #173's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/28/24, located in the EMR MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated the resident was moderately cognitively impaired. During observation and interview 10/08/24 at 9:26 AM revealed Resident #173 had a STOP Enhanced Barrier Precautions (EBP) signage on the door frame and an isolation cart outside the doorway. The Certified Nurse Aide (CNA) was observed to empty the urine from the foley catheter drainage bag. The CNA was observed with only gloves on. The CNA confirmed they only had gloves on and the resident was on EBP and should have worn a gown. During an interview on 10/08/24 at 9:30 AM, Resident #173 stated, The staff usually wore gowns and gloves when taking care of them. During an interview on 10/08/24 at 9:47 AM, the Administrator stated, All staff were aware of when to use EBP and for which residents require it. During an interview on 10/10/24 at 2:52 PM, the Infection Preventionist (IP) stated, All staff are trained on when and who to use EBP for. I go over this training each time we have a new admission it applies to and with each new infection or new occurrence when it's needed. I don't know why CNA didn't wear EBP, but he was educated again. Review of the facility policy titled, Enhanced Barrier Precautions (EBP) Policy and Procedure, dated 04/2024 revealed Policy: Enhanced barrier precautions (EBP) will be used for novel or targeted MDROs [Multidrug-resistant organisms] . Enhanced Barrier Precautions (EBP): The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and for indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Review of the facility's training check-off document titled, Personal Protective Equipment Skills Checklist, dated 09/18/21 with attached undated document defining EBP requirements in detail, Type of Precaution: Enhanced Barrier Precautions (EBP); Applies to: All residents with any of the following: Infection or colonization with an MDRO when contact precautions do not otherwise apply. Wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status; When to Use PPE: During high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator; PPE Use: Gloves and gown prior to the high-contact care activity, change PPE before caring for another resident, don before room entry, doff before room exit, face protection may also be needed; Restriction: None.

Based on observation, record review, policy review and staff interview, it was determined the facility failed to ensure resident-centered care were provided in accordance with professional standards of nursing practice and residents' comprehensive care plans. This was true for 3 of 23 residents (#4, #17, and #22) reviewed for quality of care. This deficient practice had the potential to adversely affect or harm residents whose care and services were not delivered according to accepted standards of clinical practice. Findings include: 1. Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses chronic respiratory failure with hypercapnia (increase level of carbon dioxide in your blood), myotonic (muscles are unable to relax after they contract) muscular dystrophy (a progressive muscle loss) and paroxysmal (uncontrolled) atrial fibrillation (irregular heartbeat). A physician order, dated 3/30/24, documented monitor Resident #22's bilateral lower extremities edema and notify the physician if change is noted. A care plan, revised 4/15/24, directed staff to monitor/document/report Resident #22's any signs and symptoms of CAD (coronary artery disease) such as dependent edema, changes in capillary refill, and color/warmth of her extremities to the physician. On 10/7/24 at 3:03 PM, Resident #22 stated to the surveyor her legs were red and big. CNA #1 then removed the sheet and Resident #22's right and left leg were observed to be swollen, and looked dry with flaky skin. The middle portion of her right leg was noted to be slightly red in color. A Nursing Note, dated 10/1/24 at 4:24 PM, documented, Resident has large slightly red area to BLE. Not red [warm] to touch but painful when pressure is applied. Legs have 2-3+ edema in BLE as well. Resident #22 was encouraged to wear her TED hose or other compression garment, but Resident #22 stated it would make her uncomfortable. Resident #22 was also educated to take her diuretic medication, but Resident #22 stated she didn't care and would not talk to the nurse anymore. There was no documentation in Resident #22's record the 2-3+ edema to her BLE, which was painful when pressure was applied, was referred to the physician. On 10/10/24 at 10:48 AM, the DON reviewed Resident #22's record. The DON stated Resident #22 should have been referred to the physician and she was not. 50603 3. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and chronic, hypertensive kidney disease. Resident #4's care plan, dated 7/15/22, directed staff to monitor her Hypo/Hypervolemia, and to notify the physician of irregularities. Resident #4's record did not include monitoring for Hypo/Hypervolemia. On 10/11/24 at 11:45 AM, the DON verified that the physician's orders were not being followed as Resident #4 did not have any monitoring system in place for Hypo/Hypervolemia. The DON stated if there were notifications to the physician, they might be recorded separately, after the physician signs off on the notification. Notifications are usually recorded in progress notes, but she was unable to find any relating to Hypo/Hypervolemia or Edema. A physician's order dated 5/8/23, documented to monitor for edema using the BLE (bilateral, lower extremity) Edema Scale weekly, and to notify the physician if a change in edema is noted. A review of the MAR and TAR for October 2024, documented the following BLE Edema Scale: -9/19/24: An increase from grade 2 to grade 3 -9/21/24: No recorded measurement -9/23/24: An increase from grade 1 to grade 2 -10/5/24: An increase from grade 2 to grade 3 -10/6/24: A decrease from grade 3 to grade 2 -10/7/24: A decrease from grade 2 to grade 1 -10/9/24: An increase from grade 1 to grade 2 -10/10/24: A decrease from grade 2 to grade 1 No notifications to the physician were found in the resident's record. On 10/11/24 at 11:45 AM, the DON verified that the physician's orders were not being followed. She also confirmed notifications to the physician for the changes in edema were not available. 4. Resident #17 was admitted to the facility on [DATE], with multiple diagnoses including rib fractures, chronic obstructive pulmonary disease, and diabetes. On 10/7/24 at 4:15 PM, it was observed in Resident #17's room, no date was on the O2 tubing, and the CPAP machine mask was on the floor. A physician's order, dated 9/8/24, documented to change O2 tubing, label and date, every night shift, every Sunday. A review of the TAR for September and October 2024, documented O2 tubing was changed, labeled, and dated every night shift on Sunday's. On 10/10/24 at 1:30 PM, with dayshift LPN #1 present, he verified there was no date on the O2 tubing. He stated O2 tubing should be dated by the evening staff who take care of this.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents received proper treatment to maintain foot health. This was true for 2 of 5 residents (#22 and #48) reviewed for foot care. This deficient practice created the potential for harm should residents experience complications related lack of proper foot care. Findings include: 1. Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses chronic respiratory failure with hypercapnia (increase level of carbon dioxide in your the blood), myotonic (muscles are unable to relax after they contract) muscular dystrophy (a progressive muscle loss) and paroxysmal (uncontrolled) atrial fibrillation (irregular heart beat). A care plan, initiated on 1/4/24, directed staff to refer Resident #22 to a podiatrist/foot care nurse to monitor/document foot care needs and to cut her long nails. A Nurse Practitioner (NP) progress note, dated 8/20/24 documented, Candidiasis [fungal infection] of skin and nail. A Quarterly Nursing Evaluation, dated 9/22/24, documented Resident #22's toenails were yellow. A September 2024 TAR, directed staff to check Resident #22's foot every week and notify the physician if skin issue was noted. On 10/7/24 at 3:03 PM, Resident #22's toenails were observed to be long, thick and yellowish in color. The right big toe was noted to have blackened area on its side. There was no documentation in Resident #22's record she was seen by a podiatrist or was referred to the physician regarding the condition of her toenails. On 10/10/24 at 10:19 AM, the ADON with the DON present was asked if Resident #22 was seen by a podiatrist, the ADON reviewed Resident #22's record and stated she was unable to find documentation Resident #22 was seen by a podiatrist. 2. Resident #48 was admitted to the facility on [DATE], with multiple diagnoses including respiratory failure with hypercapnia (increase level of carbon dioxide your blood), diabetes and chronic obstructive pulmonary disease. A physician order, dated 2/8/24, documented, Diabetic Foot checks every week on skin check day. Notify MD [if] skin issue is noted. A care plan initiated on 2/14/24, directed staff to refer Resident #48 to a podiatrist/foot nurse to monitor/document foot care needs and to cut long nails. A Quarterly Nursing Evaluation dated 8/24/24, the section was blank regarding the assessment on C. Skin Integrity #3 Toenails. A September 2024 TAR, directed staff to check Resident #48's foot every week and notify the physician if skin issue was noted. On 10/8/24 at 3:55 PM, Resident #48 was in bed and his toenails were observed to be thick and long. There was no documentation in Resident #48's record she was seen by a podiatrist or was referred to the physician regarding her toenails condition. On 10/10/24 at 10:19 AM, the ADON, with the DON present, was asked if Resident #48 was seen by a podiatrist, the ADON reviewed Resident #48's record and stated she was unable to find documentation Resident #48 was seen by a podiatrist.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure resident care plans were revised to reflect current needs and interventions. This was true for 2 of 23 residents (#4, and #17) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include: The facility's Care Planning Process policy, revised 5/19/23, documented the care plan must be reviewed and revised according to the RAI (Resident Assessment Instrument) process at a minimum upon admission, quarterly, and with significant change in condition and services provided or arranged much be consistent with each resident's written care plan. 1. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and chronic, hypertensive kidney disease. Resident #4's care plan, dated 6/29/22, relating to renal failure, directed staff to monitor her for signs or symptoms of hypo/hypervolemia, and to monitor/document/report her for signs and symptoms of acute failure: oliguria, and increased BUN and Creatinine. A review of the MAR/TAR for September through October 2024, failed to document any hypo/hypervolemia monitoring. On 10/11/24 at 11:45 AM, the DON verified she did not see anything in Resident #4's EHR record related to hypo/hypervolemia monitoring. She stated there was no blood work being tracked; however, Resident #4 is up for an MDS review in December and her file will open next month to be updated. 2. Resident #17 was admitted to the facility on [DATE], with multiple diagnoses including rib fractures, chronic obstructive pulmonary disease, and diabetes. On 10/08/24 at 9:13 AM, Resident #17 stated in a follow-up interview per resident's request, he stated he is trying to lose weight and he has started to take the weekly shot. A physician's order, dated 9/24/24, documented Semiglutide (an anitdiabetic medication used for the treatment of type 2 diabetes and an anit-obesity medication used for long-term weight management) administration, with weekly weights taken. A review of Resident #17's care plan, dated 9/5/24, and revised on 9/19/24, did not include any weight management interventions. On 10/11/24 at 11:46 AM, a review of Resident #17's record, with the DON, verified Resident #17's care plan was not updated with a weight management program. On 10/10/24 at 10:30 AM, during a resident requested follow-up interview, Resident #17 stated he was supposed to have CPAP machine on every night, but no one had come in to help him. A review of Resident #17's care plan, dated 9/5/24 and revised 9/19/24, does not show use of CPAP machine. A physician's order, dated 10/2/24, documented: Hook Patient up to Home CPAP with 2 LPM (liters per minute) of Oxygen continuously through device. Increase Oxygen if Pulse Oximetry Level is below 88%. A review of the MAR, for October 2024, documented beginning 10/2/24 at 7:00 PM, the CPAP mask was being placed on Resident #17. However, Resident #17 was adamant no one had helped him put the mask on before bed. On 10/11/24 at 10:45 PM, the DON stated she would investigate what happened with the CPAP mask. She verified the O2 tubing should be dated. The DON confirmed the care plan was not updated.

Based on interview, record review, and review of facility policy, the facility failed to provide activities of daily living (ADL) care for 1 of 4 dependent residents (Resident #19) who required extensive assistance with personal hygiene/showers out of a total sample of 32 residents. This deficient practice created the potential for Resident #19 to have a decrease in their quality of life. Findings include: Resident #19 was admitted to the facility on [DATE], with multiple diagnoses including multiple sclerosis. A Quarterly MDS assessment, dated 8/28/24 documented Resident #19 was cognitively intact and required assistance with bathing/showers/hygiene. Resident #19's Shower Sheets for the past 30 days documented he received two showers a week, except for two, one he refused, and one he was unavailable. During an interview on 10/07/24 at 4:12 PM, Resident #19 stated he only received one shower a week. He said his shower days were Sundays and Wednesdays and he always received a shower on Sunday, but not on Wednesday. By Sunday, my hair is always greasy and in bad shape and I need a really good shave by then. They don't say why they don't give me my Wednesday shower, but I really want my showers. I know they put I refuse a lot, but that is not the case. The resident was noted with approximately 1/4 inch of beard growth and oily unkempt hair. During a follow up interview on 10/11/24 at 1:10 PM, Resident #19 stated, I asked if I could get my shower two days ago, on Wednesday, but I never received it, as usual. I don't get bed baths, and they never tell me why. During an interview on 10/11/24 at 1:20 PM, LPN #1 stated, Resident #19 got a partial bed bath on Wednesday. I know on Sundays he gets a shower. On Wednesday he got a partial bed bath because we only had one aide on the floor that day. During an interview on 10/11/24 at 1:30 PM, the DON said Resident #19 was care planned to receive two showers a week. Everyone should have two showers a week. Review of the facility policy titled, Personal Needs, dated 12/20/22 revealed Policy: The center strives to promote a healthy environment and prevent infection by meeting the personal care needs of the residents. The center also provides the needed support when the resident performs their activities of daily living (ADLs) . The Care Plan will address the individual needs and preferences of the resident. Personal care and ADL support will be provided according to the resident's Care Plan. Compliance with care delivery needs and interventions will be determined by observation of care delivery and not through the utilization of care delivery flow record (Point of Care). Personal care and support include but is not limited to the following: bath/shower, grooming/dressing, shampoo, shave .

Based on policy review, record review, and staff interview, it was determined the facility failed to ensure a resident with mental disorders received appropriate treatment and behavioral services. This was true for 1 of 1 resident (Resident #61) reviewed for mental and behavioral health care. This failure created the potential for the resident to experience compromised physical and psychosocial well-being. Findings include: Resident #61 was admitted to the facility on [DATE], with multiple diagnoses including autistic disorder, dementia with agitation, and adult personality and behavior disorder. A social services progress noted, dated 4/19/24, documented Resident #61's previous primary care provider stated he was becoming increasingly more demented, and he may have a schizotypal personality disorder. Social services stated Resident #61 might need a psychiatric evaluation. Resident #61's care plan, dated 4/26/24 and revised on 5/3/24, documented a history or potential to demonstrate, verbal abusive behaviors such as aggressive cursing, threatening, and yelling at staff, ineffective coping skills, mental/emotional illness, and poor impulse control. The care plan directed staff to document observed behavior, and if resident became agitated, to intervene before escalation, guide away from source of distress, and if aggressive, to have staff walk away to approach later. A preadmission PASSR I was completed on 5/9/24, identifying unspecified dementia, autism, and substantial limitations in learning, self-care, capacity for living independently, and self-direction. A PASSR II evaluation was recommended. An abbreviated PASSR II was completed on 5/9/24 and 5/10/24, documenting a diagnosis of autism and stating that no specialized services were required, as Resident #61's needs would be met by the receiving facility. On 5/18/24 Resident #61 was sent to the hospital due to increasing lethargy, confusion, and decrease appetite and thirst. Resident #61 was admitted to the hospital on 5/18/24 for a consultation regarding lithium management related to his increasing lethargy, confusion, and decrease in appetite and thirst. On 5/21/24, a hospital admission history and physical, documented Resident #61 had past medical diagnoses of autism with combative behavior and dementia. A Social Services progress note, dated 6/28/24, documented Resident #61's behavior in the facility was not appropriate and his dementia had worsened. Social Services stated the safety of other residents and staff in the facility could be at risk and Resident #61 was no longer appropriate for this environment. A Social Services progress note, dated 8/1/24, documented social services was looking for alternative placement due to [Resident #61's] ongoing behavior and autism diagnosis. IDT felt that [Resident #61] might be overstimulated, and a smaller setting would be more appropriate to meet his current needs. An SBAR, dated 8/5/24, documented Resident #61 needs a psychiatric evaluation as Resident #61's medication had already been adjusted. On 9/13/24, Resident #61 was seen for a Psychiatric Initial Consultation related to assaultive/violent behaviors and crisis stabilization. The physician's report documented patient was loud and made verbal threats to staff. The report stated facility staff had reported Resident #61's behavior had been escalating, becoming loud, making threats, and frightening other residents. Although, [Resident #61] had not been physically aggressive, the report stated, [Resident #61] would kill the kitchen staff, and the facility would not be accepting him back. There was no record found where Resident #61 was seen by a psychiatrist regarding schizotypal personal disorder, or behavioral aggression prior to 9/13/24. On 10/11/24 at 1:31 PM, the Administrator stated, We have had to send Resident #61 to the hospital to get psych evaluations. No one was available to see him here as our facility is not set up for these types of evaluations. The Administrator stated the facility had been working to get Resident #61 placed into an appropriate facility to care for his specific diagnoses.

Based on review of facility policy, record review, document review, and interviews, the facility failed to ensure allegations of abuse were thoroghly investigated. This was true for 2 of 8 residents (#4, and #46) reviewed for abuse and neglect. This deficient practice created the potential for psychosocial, verbal, and physical harm whose abuse allegations were not investigated thoroughly, and measures taken to protect resident during the investigation, which placed all residents in the facility at risk of abuse. Findings include: The facility's Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property Policy, dated 8/22, documented a resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy defined Verbal and Mental abuse as oral, written, or gestured language that includes disparaging and derogatory terms to the resident or their families or within their hearing distance regardless of their age, ability to comprehend or disability, that would demean or humiliate, resulting in pain or mental anguish. Mental abuse can be verbal or non-verbal. It includes, but is not limited to humiliation, harassment, and threats of punishment or deprivation. 1. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including diabetes and chronic, hypertensive kidney disease. On 10/08/24 at 11:39 AM, Resident #4 stated, I don't feel safe with [Resident #61]. He came into my room, yelling at me, and I spoke back to him. He left. I see him around the facility, and I don't make eye contact. I look down or towards the wall. A review of progress notes from 8/5/24 documented an SBAR where Resident #61 entered multiple rooms but did not identify which rooms or which residents were involved. Review of facility's Grievances, SBARS, and I&A reports were reviewed for 2024. No reports were found. 2. Resident #46 was admitted to the facility on [DATE] with multiple diagnoses including acute and chronic respiratory failure with hypoxia (a condition in which there is a deficiency of oxygen in the body's tissues), pulmonary embolism, diabetes, and congestive heart failure. On 10/08/24 at 10:23 AM, Resident #46 stated, Resident #61 used to live across the hall from me and would wander into my room and yell at me. I didn't feel safe. I know he doesn't like women. They moved him, and it's been better, but I still don't know if I should fear him as I can't move, and [staff] don't come very quickly when I press the call light. I also think about what I have nearby to pick up and defend myself if he does come back. On 10/11/24 at 11:01 AM, LPN #2 stated she provided a grievance form to Resident #46 when Resident #61 yelled at her outside of her room. She stated this incident happened within a few months of Resident #61coming into the facility. LPN #2 also stated residents were affected by the incident. They were provided grievance forms, but I don't know if they filled them out. A progress note, dated 8/5/24, documented [Resident #61] is disruptive, aggressive, and requires more attention than this facility can provide, he requires a behavior unit. Additionally, it was documented [Resident #61] continued to have outbursts of agitation and was being intrusive by going into other residents' rooms. He was extremely aggressive, loud, and difficult to redirect. A psychiatric evaluation and medication change was asked for. A review of facility grievances for 2024, did not show any complaints regarding this incident. A review of I&A reports for 2024, did not show any documentation regarding this incident. An SBAR report, dated 8/5/24, documented that Resident #61 entered other resident's room, but did not identify which rooms or residents who were involved. On 10/11/24 at 11:23 AM, the Administrator and DON stated Resident #61 was moved to a different room after the incidents in the hallway, but they are not sure if a report was filed. They were unaware Resident #61 was entering residents' room.

Based on observation, policy review and staff interview, it was determined the facility failed to ensure medications were disposed properly. This was true for one of one staff (LPN #2) observed disposing the medications in the regular trash can. This deficient practice created the potential for harm if resident pick up and take the medication. Findings include: The facility's Destruction of Controlled Substance procedure, undated, documented under the section Disposal of Drugs - Drug Buster Drug Disposal System Remove discontinued, expired, contaminated or unusable medication from original prescription container or packaging and dispose of by placing into Drug Buster container. On [DATE], three pills were observed on top of LPN #2's medication cart and LPN #2 was looking at the computer. There was no barrier between the medication cart and the three pills. When LPN #2 saw the Surveyor, she immediately pick up the three pills and threw them in the trash can which was located on the side of her medication cart. When asked what the pills were, LPN #2 stated they were all over the counter medications and can be thrown in the regular trash can. LPN #2 also stated, if they were narcotics medications she would dispose them in the drug buster. When asked again about the names of the pills, LPN #2 stated they were ASA, metoprolol (antihypertensive) and gabapentin (anticonvulsant). [DATE] 04:26 PM, the DON stated the medications should have disposed in the drug buster and not in the regular trash can. The Drugs.com website, accessed on [DATE], stated gabapentin and metoprolol are prescription medications.

Based on policy review, facility document review, and staff interview, it was determined the facility failed to ensure the Quality Assessment and Assurance (QAA) committee took actions to identify and resolve systemic problems. This failure affected 74 of 74 residents residing in the facility. The deficient practice resulted in insufficient monitoring and resolution of resident grievances which had the potential to cause residents psychosocial harm and/or decreased quality of life. Findings include: The facility's Quality Assurance and Performance Improvement (QAPI) Plan policy, revised May 2023, documented the QAPI plan would identify and use data to monitor their performance. The policy documented some of the sources for collecting data would be abuse, neglect, and maltreatment reports, resident or family grievances, and resident council meeting minutes. The policy documented the QAA committee would review data on a quarterly basis and the administrator had responsibility and was accountable for ensuring QAPI was implemented. The facility's Grievance policy, revised 1/27/2023, documented responsibilities were directed and supervised by the Grievance Officer which included review of resident grievances at QAPI meetings for the team to identify trends and prompt additional action when necessary. These policies were not followed. On 11/2/23 at 10:49 AM, the Administrator stated the QAPI team met monthly. The previous 6 months of QAPI meeting notes were requested. On 11/2/23 at 3:00 PM, the Administrator provided two documents labeled QAPI created by the prior administrator, dated 4/27/23 and 5/25/23. He also provided QAPI meeting attendance rosters and data dated 7/27/23, 8/31/23, 9/21/23, and 10/12/23. There was no data grievances were reviewed for 4 months, from July 2023 to October 2023. On 11/3/23 at 1:10 PM, the Administrator stated the facility could not provide documentation grievances were reviewed at the QAPI meetings for the last 4 months. He stated he did not know when the last time grievances were reviewed at the QAPI meeting.

Based on policy review, review of grievances, and staff interview, it was determined the facility failed to ensure resident grievances were investigated and resolutions were documented. This deficient practice placed all residents at risk of having unmet needs and poor quality of life when their concerns were not properly addressed. Findings include: The facility's grievance policy, revised 1/27/23, stated the Grievance Officer supervised and documented the details of the investigation and resolution of grievances. This policy was not followed. On 10/31/23 at 2:00 PM, residents at the resident council meeting stated they were unhappy with the facility's grievance process. They explained when they submitted a grievance, they did not know how the facility was addressing their concerns. Residents attending the meeting also stated they filed a grievance concerning staff training and did not receive a response. On 11/1/23 at 05:26 PM, the Administrator stated the facility was unable to produce documentation the grievance submitted by the resident council about staff training was addressed. On 11/2/23 at 10:49 AM, the Administrator stated he was the facility's Grievance Officer. He stated grievances received the day prior were discussed in the IDT stand up meeting every morning. The Administrator also stated he delegated the grievance to the related department head. On 11/3/23 at 1:10 PM, the Administrator stated each department was responsible for follow-up for grievances in their area. He stated he was responsible for documenting the grievance and making sure it's getting done. When asked if he, as the Grievance Officer, was the person responsible for supervising the resolution of grievances, he replied yes.

Based on observation and staff interview, it was determined the facility failed to ensure licensed nurses were competent to administer insulin using a pen. This was true for 17 of 17 licensed nurses whose training records were reviewed for competencies. This had the potential to adversely affect residents who received insulin injections. Findings include: The facility's Insulin Injection policy, dated 12/22/22, documented Hold the insulin pen so you can read the name of the insulin. Looking at the dose window, dial to 2 units by turning the dosage selector forward. With the needle pointing up, press the injection button firmly with thumb and look for drops of insulin to come out of the tip of the needle. The [NAME] Manual of Medical-Surgical Nursing (10th edition, p. 579), documented insulin pen devices must be primed to ensure there is no obstruction and to clean any air in the needle. On 10/31/23 at 11:50, LPN #2 prepared a Lispro insulin pen for administration to Resident #25. LPN #2 did not prime the insulin pen prior to administering the insulin to Resident #25. A request was made on 11/3/23 to review the training and competencies for administration of insulin using a pen for licensed nurses working at the facility. On 11/3/23, the ADON provided a written statement, dated the same day and signed by her, which stated the facility did not have documentation the licensed nurses working at the facility had competencies for insulin administration, glucometer control log, and blood sugar checks.

Based on observation and interview, it was determined the facility failed to ensure food containers were appropriately labeled and free of spillage; food processing equipment was cleaned after use; and containers for dish storage were free of debris. This had the potential to affect 74 of the 74 residents who resided in the facility and consumed food prepared from the facility's kitchen. Findings include: During the initial kitchen tour observation on 10/30/23 at 10:58 AM, one of three plastic bins had dried brown residue on the outside. The Robo Coup (a food processor) had dried beige-colored residue on it. During an additional tour of the facility's kitchen on 11/2/23 at 8:15 AM, the following concerns were identified: In the refrigerator, there were 1 of 5 containers of small curd cottage cheese that were previously opened without an opened date, and 2 jars of condiments (1 jar of tartar sauce and 1 jar of Dijon mustard) with spillage on the outside. The Robo Coup machine had dried beige-colored splatter on the front face plate. The metal cart that housed the warming pans was observed to have the following: - The first shelf had 2 of 10 pans with greasy residue on the outside of the pans. - The second shelf had 1 of 23 pans with greasy residue on the outside of the pans. - The third shelf had 2 of 12 pans with greasy residue on the outside of the pans. The cart holding the cleaned dome coverings for the plates had dirt debris with brown gummy residue on the cart. During the Resident Council meeting on 10/31/23 at 3:34 PM, 15 residents attended the meeting and complained the cups and glasses were not clean. They stated the items had some type of residue in the bottom. During an interview with the Dietary Manager on 11/2/23 at 11:30 AM, she verified the observations and stated the staff were responsible for wiping down the condiment jars after each use and all open containers should be dated when opened. The Dietary Manager stated since the dish machine was in the process of being repaired it was difficult to clean the pans of the greasy film.

Based on observation, review of the Food and Drug Administration (FDA) Food Code, and staff interview, it was determined the facility failed to ensure trash was contained in the facility's dumpsters with closed lids for two of three outside trash dumpsters. This created the potential for insect and pest infestation. Findings include: The FDA Food Code 2022 states: 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered .with tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT. 6-501.114 Maintaining Premises, Unnecessary Items and Litter. The PREMISES shall be free of: (A) Items that are unnecessary to the operation or maintenance of the establishment such as EQUIPMENT that is nonfunctional or no longer used; and (B) Litter. These guidelines were not followed. On 11/2/23 at 11:45 AM, the facility's dumpster area was observed. Two of three dumpsters had the lids open. One of the dumpsters had trash overflowing onto the ground surrounding the dumpsters. On 11/2/23 at 2:30 PM, the Dietary Manager stated all departments placed trash in the dumpsters, but she thought it was the maintenance department who ensured the area around the base of the dumpsters was clean and the lids were closed. On 11/3/23 at 9:45 AM, the Maintenance Assistant stated he was responsible for ensuring the areas around the dumpsters were kept clear. The Maintenance Assistant stated he was not aware that the lids to the dumpsters were left open.

Based on observation, review of the FDA Food Code, and resident and staff interview, it was determined the facility failed to ensure resident meals were palatable and maintained their correct temperature. This directly impacted 2 of 2 residents (#10 and #41) and had the potential to affect the other 72 residents who dined in the facility. This failed practice had the potential to negatively affect residents' nutritional status and psychosocial well-being. Findings include: The FDA Food Code 2022 states hot food will be maintained at 135 degrees F or above. On 10/30/23 at 10:45 AM, Resident #41 stated the meals were served in styrofoam containers and the food was usually cold and tasted bland. On 10/31/23 at 9:10 AM, Resident #10 stated the food was not tasty and most of time the food was served cold. On 10/31/23 at 3:34 PM, during the Resident Council meeting, residents complained about the food temperatures. During an observation of the lunch meal service on 11/2/23 beginning at 11:35 AM, the steam table food temperatures were over 140 degrees F as follows: Chicken stir fry 180 degrees F Mechanical soft chicken 177 degrees F Pureed chicken 185 degrees F Mashed potatoes 165 degrees F Pureed potatoes 180 degrees F Rice 174 degrees F Pureed rice 168 degrees F Vegetables 161 degrees Soup 185 degrees F The last resident meal cart left the kitchen on 11/2/23 at 12:18 PM. and the last tray was served on the 600 hall at 12:29 PM. A tray from the last meal cart was sampled by the Dietary Manager and surveyors. The food temperatures were as follows: Chicken stir fry was 116.6 degrees F Rice 117.5 degrees F Vegetables 100.4 degrees F Soup 132.2 degrees F The Dietary Manager tasted the food and stated the food tasted good but could be warmer. The survey team tasted the food with the following conclusions: the food tasted lukewarm, the vegetables tasted bland, and the chicken was salty due to the marinade sauce. During an interview on 11/2/23 at 1:10 PM, the Dietary Manager stated it was difficult to keep the food warm for long periods of time using the Styrofoam plates.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when hand hygiene was not performed during cares and food preparation. This directly impacted 1 of 4 residents (Resident #42) observed during resident care and had the potential to impact the other 70 residents residing in the facility. These failures had the potential to place residents at risk for cross contamination and infection. Findings include: The CDC website, updated on 3/15/16, accessed on 11/8/23 at 10:38 AM, stated hand hygiene should be during the following times: - Before preparing or eating food - Before touching your eyes, nose, or mouth - Before and after changing wound dressings or bandages - After using the restroom - After blowing your nose, coughing, or sneezing - After touching surfaces such as bed rails, bedside tables, doorknobs, remote controls, or the phone 1. Resident #42 was admitted to the facility on [DATE], with multiple diagnoses including schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania) and muscle weakness. A quarterly MDS assessment, dated 9/9/23, documented Resident #42 was cognitively intact and required physical assistance with hygiene as well as set up assistance with meals. Resident #42's care plan, dated 5/3/23, directed staff to assist with hand hygiene frequently with a focus before and after meals as well as before and after group activities. On 10/30/23 at 12:43 PM, Resident #42 was observed sitting up in bed with her lunch meal in front of her. She was observed to have a brown clay substance on both of her hands while picking up her sandwich. On 10/30/23 at 12:45 PM, LPN #1 stated Resident #42 was eating with feces on her hands due to her behaviors. She also stated it was not a sanitary condition for Resident #42 to eat with dirty hands. 16752 2. During an observation of lunch meal preparation on 11/02/23 at 10:20 AM, DA #1 was observed handling fresh vegetables and items on the food preparation table. She was wearing a glove on her left hand but not her right hand. DA #1 then donned a glove on her right hand and proceeded to cut the vegetables without performing hand hygiene before donning the glove. During an interview on 11/2/23 at 3:35 PM, DA#1 stated she was wearing a glove on one hand when removing the vegetables from the refrigerator and did not sanitize her other hand before donning the right glove. The Dietary Manager who was present during the interview, stated DA #1 did not follow appropriate hand hygiene practices when she handled the food, prepared the table, and donned new gloves.

Based on record review, review of the State Long-Term Care Reporting Portal, review of facility policies, and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This affected 1 of 6 residents (Resident #1) reviewed for medication administration. Resident #1 was harmed when she did not receive 13 doses of short-acting insulin for 4 consecutive days and required hospitalization for emergency treatment for hyperglycemia. Findings include: The facility's Physician's Orders policy, revised on [DATE], documented a nurse will confirm accuracy of orders by leaving new or changed orders in the queue for a second licensed nurse to verify. The second nurse will review the orders for transcriptions errors and errors of omission. The facility's procedure for managing hospital discharge orders documented, The center will obtain the appropriate physician's orders for the resident's immediate care at the time the resident is admitted . This allows the center to be prepared to manage the clinical needs of the resident and allows for efficient utilization of clinical and financial resources across the care continuum. These procedures were not followed. A State Portal incident #32860 documented a facility-reported incident related to medication errors. The report documented a resident was hospitalized for hyperglycemia after the facility staff failed to administer her short-acting insulin for 4 days. The report documented the facility initiated a self-imposed plan of correction including the development of new policies and procedures to prevent additional occurrences and staff education related to the new policies and procedures. Resident #1 was admitted on [DATE] with multiple diagnoses including congestive heart failure (a chronic condition in which the heart does not pump blood efficiently), type 1 diabetes, and chronic kidney disease. Resident #1 was admitted to the facility on the evening of [DATE] from a local hospital. Her transfer orders included 5 units of Lantus (a long-acting insulin) to be given at bedtime, and ,d+[DATE] units of Lispro (a short-acting insulin) to be given before meals and at bedtime (4 times per day) according to a blood sugar sliding scale. Resident #1's MAR documented she had received 9 units of Lispro, as ordered, at bedtime on [DATE] and 4 units of Lispro, as ordered, before her breakfast on [DATE]. The MAR documented the Lispro order expired on [DATE] at 9:27 AM and Resident #1 did not receive any further doses of Lispro from [DATE] to [DATE], when she was hospitalized . Resident #1's nurse progress notes, dated [DATE], signed by a facility LPN, documented the facility had transported Resident #1 to her nephrology appointment where she experienced blood-tinged vomitting and became difficult to arouse. She was transported to the hospital ED for assessment and treatment. Resident #1's emergency department provider notes, dated [DATE], signed by the hospital physician, documented Resident #1 was diagnosed with DKA (diabetic ketoacidosis is a serious complication of diabetes that develops when the body does not have enough insulin). In an interview on [DATE], beginning at 10:25 AM, the facility's Regional Director of Clinical Operations, Resident #1's Portal incident and medical record were reviewed in her presence. She confirmed Resident #1 should have received 3 additional doses of Lispro on [DATE], 4 doses on [DATE], 4 doses on [DATE], and 2 doses of Lispro before breakfast and lunch on [DATE], yet the doses were not administered. When asked why the doses were not given, she stated Resident #1's Lispro order had been changed and renewed on [DATE], and the new order was not activated in the electronic medication record by the facility nurses, leaving the order as pending. She stated the nurses, when interviewed, stated they were not familiar with the procedure to check for and activate pending medication order changes and felt they were too busy to notice the medication changes.

Based on policy review, observation, and staff interview, it was determined the facility failed to ensure a) Designated staff were assigned each shift to work only with COVID-19 positive residents to prevent the transmission of COVID-19 and b) respiratory equipment was cleaned and disinfected following manufacturer instructions. The facility's failure to maintain infection control measures to prevent facility transmission placed all residents in the facility and staff working in the facility who tested negative for COVID-19 or whose COVID-19 status was unknown at risk for serious harm, impairment, and/or death related to COVID-19. COVID-19 is an infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death. Findings include: 1. The facility failed to ensure it had dedicated staff to work only in the COVID-19 positive unit and those staff did not go between the COVID-19 positive residents and COVID-19 negative residents or residents whose status was unknown. The facility also failed to ensure therapy staff working on the quarantine unit (residents whose COVID-19 status was unknown) go through the COVID-19 positive unit, as follows: During the entrance conference on 2/29/21 at 8:46 AM, the Administrator stated they had 1 licensed nurse and 1 CNA dedicated to both the COVID-19 positive unit and the quarantine unit. The Administrator stated the units were separated by a plastic zippered wall and the licensed nurse and the CNA worked both units. On 2/9/21 at 10:02 AM, RN #1 was asked about the policy for COVID-19 positive residents with ventilators. RN #1 stated she would close the resident's door and call for direction from her supervisor. RN #1 stated the same nurses took care of COVID-19 positive and COVID-19 negative ventilated residents as that was what they did in the past. On 2/9/21 at 2:54 PM, RN #2 was asked about resident care in the quarantine and COVID-19 positive unit. RN #2 stated staff worked both units throughout their shifts. RN #2 stated the units were separated by a plastic zippered barrier. RN #2 stated staff entered through the COVID-19 positive unit and then proceeded through the plastic barrier to work with the residents in the quarantine unit. RN #2 stated staff then proceeded back through the plastic barrier to work with the residents in the COVID-19 unit. RN #2 stated that she was given two N-95 facemasks for each shift. RN #2 stated 1 mask was for the quarantine unit and 1 mask was for the COVID-19 positive unit. RN #2 stated she removed all her PPE while in the quarantine unit, donned clean PPE and a new N-95 mask, and then enter the COVID-19 positive unit through the plastic zippered barrier. She stated she completed her cares in the COVID-19 positive unit, then removed all her PPE including the N-95 mask in the COVID-19 positive unit, and then entered the quarantine unit through the plastic zippered barrier. RN #2 stated after she re-entered the quarantine unit, she put on her previous N-95 facemask and a clean gown. On 2/9/21 at 3:20 PM, PT #1 entered the quarantine unit. He stated his routine was to see residents in the quarantine unit first and then residents in the COVID-19 positive unit if necessary. He stated he exited the quarantine unit by walking through the COVID-19 positive unit and then to his office which was located on the other side of the COVID-19 positive unit. He stated he then went through the closed fire doors to the physical therapy office and typed up the day's notes. The facility's failure to ensure it had dedicated staff placed all residents in the facility and staff working in the facility who tested negative for COVID-19 or whose COVID-19 status was unknown, at risk for serious harm, impairment, and/or death related to COVID-19. On 2/9/21 at 4:50 PM, the Administrator, DON, and ICP were verbally informed and were provided written notification of the Immediate Jeopardy (IJ) determination at F880. On 2/10/21 at 3:00 PM, the facility provided a plan to remove the immediacy. The facility alleged the immediacy was removed on 2/10/21 at 3:00 PM. The removal plan was accepted on 2/10/21 at 3:00 PM. The facility's IJ removal plan included the use of dedicated staff to work only in the COVID-19 positive unit and the quarantine unit each shift and ensure those staff do not go between the positive residents, negative residents, or residents with an unknown COVID-19 status. The removal plan included staff education related to not crossing barriers between negative and positive units, remaining in their assigned areas for the duration of their shifts, and not entering offices or any other part of the building once they were in the COVID-19 unit or the quarantine unit. The removal plan stated education was to be conducted before all staff were allowed to work. The removal plan stated therapy staff were educated on proper entrances and exits to prevent crossing of barriers when accessing their offices. Surveyors completed onsite verification of the removal of the IJ and confirmed the IJ was removed as of 2/10/21 at 3:00 PM. On 2/11/21 at 5:00 PM, the Administrator, DON, and the ICP were verbally informed the immediacy was removed based on the onsite verification the IJ removal plan was implemented. 2. The facility's policy, titled Changing Disposable Equipment, undated, stated ventilator circuits were to be changed every 90 days and as needed, and to change bacteria, vent, and suction filters every thirty days. It also stated the heat and moisture exchanger was to be changed every day and as needed. The user manual for the Trilogy 202 ventilator documented the ventilator's exterior surface and the detachable battery pack should be cleaned before and after each patient use. It documented the following cleaning agents may be used to clean the exterior of the ventilator: soap and water, 3% hydrogen peroxide, 91% [MEDICATION NAME] alcohol, or a 10% bleach solution. It further stated that cleaning the patient circuit was important as circuits infected with bacteria may infect the user's lungs and to follow the institution protocol for cleaning the circuit. This policy and the manufacturer instructions were not followed. Resident #6 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. This limits air movement through the body, which means that less oxygen gets in and less carbon [MEDICATION NAME] gets out), dysphagia (difficulty swallowing), and [DIAGNOSES REDACTED] (spine and spinal cord deformity). Resident #6 used a Trilogy 202 ventilator with a continuous positive airway pressure setting at night to help with breathing. Resident #6 was diagnosed with [REDACTED]. On 2/10/21 at 2:00 PM, Respiratory Therapist #1 was asked how he cleaned a ventilator after use by a COVID-19 positive resident. He stated he would ask the Respiratory Manager. On 2/10/21 at 2:05 PM, the Respiratory Manager was asked how the facility cleaned a ventilator used by a COVID-19 positive resident. She stated the Respiratory Therapist would not open the circuit. The Respiratory Manager said the nebulizer treatments would probably be discontinued, and the Respiratory Therapist would not do inner cannula (a removable, reusable inner tube that fits within the main outer lumen of a [MEDICAL CONDITION]) changes. When asked how they cleaned the ventilator after use, she stated they did not have a policy, but would change the intake filter and wipe the ventilator down twice with disinfecting wipes prior to marking it cleaned and ready for re-use. The Respiratory Manager did not include cleaning the ventilator's circuit and the battery pack per the manufacturer's instructions. The DON stated the facility did not have a COVID-19 policy for ventilator care or a policy related to the treatment of [REDACTED]. She stated they used the CDC for guidance. On 2/11/21 at 12:19 PM, the ICP was asked about the policy for ventilator care and cleaning of ventilators for residents who were positive for COVID-19. The ICP stated there was nothing specific for ventilators in the facility's COVID-19 handbook and the facility had nothing specific in writing regarding care of ventilated residents with COVID-19. She stated, We refer to (the State Agency's Bureau Chief). The facility's Infection Prevention and Control policies, dated July 2020, did not include care and treatment of [REDACTED]. When asked, the DON stated during an interview on 2/11/21 beginning at 2:47 PM, they did not have infection control policies related to the use of ventilators or using ventilators with COVID-19 positive residents.

Based on observation, record review, and resident and staff interview, it was determined the facility failed to ensure each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 3 of 7 residents (#2, #4, and #6) whose records were reviewed. This resulted in a lack of needed care and services to meet residents' needs and resulted in harm to Resident #2 when she developed acute aspiration pneumonia and acute [MEDICAL CONDITION] resulting in hospitalization . Findings include: The facility's Episodic Charting procedure, undated, stated significant resident care issues were to be documented until stabilized or resolved. The document further stated the IDT would determine when the resident was stable, or the situation was resolved. This procedure was not followed. 1. Resident #2 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. The Lippincott Advisor, revised 7/10/20, stated nursing care for residents with spinal cord injuries in the long-term care setting included interventions for evaluating neurological status, observation of deteriorating respiratory functions, and vital signs. It also documented pneumonia as being a complication with [MEDICAL CONDITION] and aspiration pneumonia as being a type of pneumonia caused by impaired swallowing. The American Spinal Injury Association published an article on 4/14/12, titled Competent Care for Persons with Spinal Cord Injury and Dysfunction in Acute Inpatient Rehabilitation which documented nurses working with people with spinal cord injuries must have experience with among other things: neurological assessment, autonomic dysreflexia and autonomic instability, nutrition, and respiratory complications. a. Resident #2's physician order, dated 2/26/20, stated Resident #2 was on a dysphagia advanced texture diet with a thin consistency and her physician discharge summary from a previous facility, dated 2/25/20, stated physical therapy continued to work with Resident #2 on her swallowing issues. Resident #2's interdisciplinary discharge instruction notes, dated 2/25/20, stated Resident #2 was on a dysphagia diet and continued to have difficulties with meat items. Resident #2's speech therapy notes, dated 2/26/20, included recommendations that Resident #2 alternate liquids and solids, be given small bites, and attempt to sit at 80 degrees when eating. Resident #2's progress notes and care plan did not include documentation the speech therapy recommendations were implemented and followed. Resident #2's nursing notes did not include assessment information related to how Resident #2 ate her meals or how she swallowed food and liquids. There was no documentation if resident #2 was positioned to sit at 80 degrees to eat. b. The Mayo Clinic website, accessed on 2/24/21, included a section on low blood pressure. This section stated, some experts define low blood pressure as readings lower than 90 mm Hg (millimeters of mercury) systolic (the top number in a blood pressure reading), or 60 mm Hg diastolic (the bottom number in a blood pressure reading). If either number is below that, the blood pressure is lower than normal. The website also stated severely low blood pressure can deprive the body of enough oxygen to carry out its functions, leading to damage to the heart and brain. Resident #2's admission evaluation, completed 2/25/20, stated Resident #2's breath sounds were clear, unlabored, and she had no cough. Resident #2's record documented she had abnormal blood pressure readings, as follows: - 2/26/20 at 5:48 AM: 52/40 - 2/27/20 at 5:51 AM: 76/48 - 2/27/20 at 1:23 PM: 76/44 Resident #2's record did not include documentation of physician notification or a nursing assessment related to the abnormal blood pressures. Resident #2's care plan, initiated on 2/27/20, under the focus of autonomic dysreflexia, stated staff were to take vital signs and notify the physician of any abnormal readings. The care plan did not include the frequency the vital signs were to be taken. The next nursing assessment for Resident #2 was documented on 2/28/20 (3 days later). Resident #2 was diagnosed with [REDACTED]. The Mayo Clinic website, accessed on 3/1/21, included a section on pulse oximetry and hypoxemia. The website stated a pulse oximeter is a device that helps to assess breathing by measuring the oxygen saturation of arterial blood. The website stated hypoxemia is a below-normal level of oxygen in the blood and normal pulse oximeter readings usually range from 95 to 100 percent. Values under 90 percent are considered low. The website also stated one of the common causes of hypoxemia was pneumonia. The Cleveland Clinic website, accessed on 3/2/21, included a section about hypoxemia. The website stated complications or side effects of hypoxemia could be fatal if severe in the short term and can affect the heart or brain if it persists over a long period of time. On 2/28/20 at 2:41 PM, a respiratory note documented Resident #2 had bilateral rhonchi (coarse rattling respiratory sounds usually caused by secretions in the [MEDICATION NAME] airways in both lungs) and expiratory wheezes with a blood oxygen level of 79 percent when breathing room air. The respiratory note also documented Resident #2 had a temperature of 101 degrees Fahrenheit and was placed on supplemental oxygen at 25 liters per minute. Resident #2's record did not include additional nursing assessment information related to her respiratory status, including a re-evaluation of vital signs, including her oxygen levels after the initial 79 percent on room air was noted. A nursing note, dated 2/28/20 at 4:40 PM, documented Resident #2 continued to have a decrease in oxygen saturation and was transported to a local hospital by ambulance. The nursing note did not include information related to Resident #2's oxygen saturation level or her vital signs. The U.S. National Library of Medicine's website, Medline Plus, accessed on 3/1/21, included a section on aspiration pneumonia, last reviewed on 7/23/19, stated Aspiration pneumonia occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed into the esophagus and stomach. One of the risk factors the website stated was problems with swallowing. The website listed possible complications of aspiration pneumonia included lung abscess, shock, spread of infection to the bloodstream, spread of infection to other areas of the body, [MEDICAL CONDITION], and death. On 2/11/21 at 12:02 PM, when asked about residents with [MEDICAL CONDITION] and aspiration risks, the DON stated to keep their heads up to facilitate swallowing. When asked about Resident #2, the DON stated she would expect a physical assessment on anyone with [MEDICAL CONDITION] daily. When asked if she would expect a nurse on the 600 unit (where residents with tracheostomies and requiring the use of ventilators resided) to understand the signs and symptoms of autonomic dysreflexia, she stated yes, the nursing staff were educated on that. When told Resident #2 was hypotensive several times and there was no documentation of assessment, she stated if it was not documented it was not done. 2. Resident #6 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #6's care plan, revised 12/8/20, stated Resident #6 used a ventilator each night on the [MEDICAL CONDITION] (continuous positive airway pressure) setting, and he used the [MEDICAL CONDITION] setting with daytime naps. The intervention section stated Resident #6 was to be positioned with proper body alignment for optimal breathing. It was unclear what was meant by proper body alignment. Resident #6 was diagnosed with [REDACTED]. Resident #6's record did not include documentation of a nursing assessment from 11/1/20 until 1/17/21 (a total of 77 days). A nursing note, dated 1/17/21, documented Resident #6 experienced shortness of breath while lying flat. The nursing note stated Resident #6 needed monitoring for wheezing and to elevate his head and for him to sit upright. A respiratory therapy progress note for Resident #6, dated 2/1/21 at 4:53 PM, documented Not Today. There was no further explanation as to the meaning of the entry. On 2/9/21 at 10:12 AM, Resident #6 was observed sleeping in bed with his [MEDICAL CONDITION] on. The head of his bed was elevated and he was positioned midway down in the bed. He was lying flat and his feet were touching the footboard. He was snoring with his [MEDICAL CONDITION] machine on. On 2/10/21 at 2:31 PM, Resident #6 was observed lying flat in bed and his feet were touching the footboard. When asked, Resident #6 stated he slid down in bed and had to call for people to help him get back up numerous times per day. On 2/9/21 at 9:55 AM, RN #1 was asked about education and nursing care regarding [MEDICAL CONDITION] and [MEDICAL CONDITION]. RN #1 stated she had been a nurse for [AGE] years and we are over regulated and get the crap fined out of us because we don't have a homelike environment. On 2/11/20 at 12:02 PM, the DON was asked about the care of residents with respiratory issues. The DON said the staff were to keep moving the residents up in bed however many times it took, The DON stated there was no policy for the care of residents with [MEDICAL CONDITION] or [MEDICAL CONDITION]. When asked about specialized training related to residents with respiratory concerns or who used ventilators, the DON stated nurses were oriented to the unit by the respiratory therapists. When asked for education and training documentation, the DON stated some nurses did not have documentation of orientation and were working in the ventilator unit. The DON stated the facility did not have a COVID-19 policy for ventilator care or a policy related to the treatment of [REDACTED]. She stated they would go to the CDC for guidance. 3. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #4's physician order, dated 11/25/20, stated Resident #4 was to receive [MEDICATION NAME] 5 mg each morning for hypertension. Resident #4's physician order, dated 11/27/20, stated Resident #4 was to receive [MEDICATION NAME] 100 mg three times a day for Neuralgia (stabbing, burning, and often severe pain due to an irritated or damaged nerve) of upper extremities, Aspirin 81 mg each morning for heart health, and Celecoxib 100 mg each morning for muscle spasms. Resident #4's physician order, dated 11/30/20, stated Resident #4 was to receive [MEDICATION NAME] Liquid to be applied to her inner ear 4 times a day for otalgia (ear pain). Resident #4's Medication Administration Records (MAR) documented Resident #4 did not receive her medications, as follows: - 12/1/20: Resident #4 did not receive her [MEDICATION NAME] and [MEDICATION NAME] Liquid and she did not receive the evening dose of [MEDICATION NAME]. - 12/2/20: Resident #4 did not receive her [MEDICATION NAME], Celecoxib, and Aspirin. Resident #4 did not receive the morning dose of [MEDICATION NAME] Liquid. - 12/4/20: Resident #4 did not receive the morning dose of [MEDICATION NAME]. A progress note, dated 12/1/20 at 9:04 AM, regarding medication administration, documented na (not available), will follow-up with pharmacy. A progress note, dated 12/1/20 at 6:16 PM, regarding medication administration, documented not available per pharmacy. A progress note, dated 12/1/20 at 8:51 PM, regarding medication administration, documented medication is not yet in stock-pending delivery from pharmacy, will admin (administer) when medication arrives per orders, pt (patient) aware. WCTM (will continue to monitor) for pain and/or worsening of s/s (signs/symptoms). A progress note, dated 12/2/20 at 10:31 AM, regarding medication administration, documented unavailable. There was no corresponding progress note regarding the missed dose of [MEDICATION NAME] on 12/4/20 for Resident #4. On 2/11/21 beginning at 2:47 PM, the DON stated during an interview the nurses were to reorder medications and if the medication was an over-the-counter drug, the nurses were to notify her (the DON) and she would pick up the medication from a local pharmacy.

Based on record review, observation, staff, resident, and family member interview, policy review, and review of staffing schedules and in-service training records, it was determined the facility failed to ensure allegations of mistreatment, sexual assault, elopement, and injury of unknown origin were investigated and/or reported for 4 of 24 sampled residents (#3, #14, #20, and #23). This deficient practice placed Resident #3 in Immediate Jeopardy (IJ) for serious harm, impairment, or death. Specifically, Resident #3 alleged he was mistreated by a CNA who was allowed to provide cares for his roommate for 5 months following the allegation, which was neither reported nor investigated by the facility. Resident #3 was in Immediate Jeopardy for repeat instances of mistreatment and continued to experience anxiety when the alleged perpetrator was allowed to continue assisting with cares for his roommate over a 5-month period. Resident #23 was also harmed when she was sexually assaulted by Resident #24, whose care plan stated he was to receive 1:1 supervision. A thorough investigation of the incident was not completed. Additionally, Resident #14 presented with significant bruising of unknown origin that was neither reported nor investigated in a timely manner by the facility. This deficient practice placed Resident #14 at risk of potential abuse as the source of her injuries had not been investigated. The facility failed to investigate a missing resident (Resident #20) who was not located until he was admitted to a hospital approximately 36 hours later with [DIAGNOSES REDACTED]. The facility failed to investigate this elopement as a possible case of neglect or address supervision concerns for other residents in the facility who were also at risk of elopement. Findings include: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS assessment, dated 5/16/16, documented Resident #3 was cognitively intact, and totally dependent on at least two staff for all activities of daily living due to paralysis below the neck from a sudden onset of [DIAGNOSES REDACTED], a rare [DIAGNOSES REDACTED] disorder in which the immune system attacks healthy nerve cells in the peripheral nervous system leading to paralysis. On 11/2/16 at 4:00 pm, Resident #3's family member stated, Right after we got here we had a problem. A night shift CNA (#6) was rough with him. She tried to turn him by herself and when she left the room his head, arms, and legs (were) hanging off of the bed. He uses his head to press against the call light and he was unable to use his call light. He told me that he was left in that position for several hours and unable to ask for help. He told me a nurse came into the room several hours later and with the help of another CNA repositioned him correctly. I wrote a note about it and gave it to the Unit Manager who said she would write it up. I never heard what happened, but she (CNA #6) didn't come back to care for him again. On 11/2/16 at 4:00 pm, Resident #3, when asked if he felt CNA #6 was rough with him, nodded his head, Yes. The family member stated, The Unit Manager asked him if it would be alright if she brought (CNA #6) into the room to teach her how to reposition him. He told her, 'No,' by moving his head from side to side. She is the only one (staff) he has a problem with and he insisted that she not come back into the room. During this conversation with the family member on 11/2/16 at 4:00 pm, Resident #3, who was unable to speak due to a [MEDICAL CONDITION] providing oxygen via ventilator, motioned for a communication board. The resident then nodded his head back and forth or side-to-side as his family member pointed out letters that eventually spelled, Tell her what happened. The family member stated, On 10/2/16 he told me something that happened the night before on the night shift. He said there were only two people on the shift and one of them was (CNA #6). He said a nurse came into the room and told him she couldn't reposition him by herself and the other CNA on duty was (CNA #6), who was not allowed in the room. He wasn't repositioned or changed (when incontinent) all night. The family member, who kept a journal in which she documented what Resident #3 reported to her, contained the following entry: 10/2/16 - Arrive 8:35 leave 9:45 couldn't get changed during night-called for help-because other aide was one he had problems with. She refused to come in, he wouldn't have her. The family member stated, I told (the DON) and he said, We have trouble finding CNAs that are comfortable with vent patients. On 11/3/16 at 9:30 am, UM #1 stated, I remember a conversation I had with (Resident #3 and his family member) and I took it to (the DON); I don't know if they investigated it or not. (Resident #3 and his family member) said they did not want (CNA #6) to go back into the room. I don't recall getting any written note from the family member. I might have been the one who requested that (CNA #6) not go back into the room, I just can't recall and I don't have anything in writing. On 11/3/16 at 11:00 am, the DON said he was aware CNA #6 was not allowed into Resident #3's room to provide care, but did not know the reason. The DON stated he scheduled CNA care assignments and that he assigned CNA #6 to an area of the facility where she would not come into contact with Resident #3 or his family member. On 11/3/16 at 12:20 pm, UM #1 stated she did not initiate an investigation when Resident #3's family member spoke to her several months previous. UM #1 stated, The only nurse aide that (Resident #3) and his family member had a problem with was (CNA #6). I counseled (CNA #6), but I didn't write anything up. I talked to the DON and we tried to brainstorm . On 11/3/16 at 12:30 pm, LN #2 said she worked the night shift and knew CNA #6 was not allowed to provide care to Resident #3. LN #2 stated, When (CNA #6) works . we have to watch her call lights because she is not allowed to care for (Resident #3). (CNA #6) trades with someone else on duty when it comes to (Resident #3's) care; everyone knows she can't go in there. On 11/3/16 at 12:40 pm, Resident #3's family member stated she met with the Administrator and DON on 10/10/16, at which time she stated she did not want CNA #6 in the resident's room. At the time of this interview, Resident #3 stated his participation in Speech Therapy enabled him to now speak. Resident #3 stated, She's the only one I had trouble with. At that time I had no strength in my neck and I couldn't position my head. She left me on my bedsore for hours and I couldn't use my call button. I couldn't explain to them then what I needed and they didn't have time to use the communication sheet. When asked if he felt he had been mistreated by CNA #6, Resident #3 said, Yes. On 11/3/16 at 12:45 pm, CNA #4 said she knew CNA #6 was not allowed in Resident #3's room and stated, I heard (CNA #6) was being too rough when changing him. A couple of days ago (CNA #6) worked that night and the resident and his (family member) said he wasn't changed or touched all night because (CNA #6) could not go in there and they were short (staffed) that night. On 11/3/16 at 1:00 pm, the Administrator stated he recalled the meeting with Resident #3's family member on 10/10/16, however, he said he was not aware of an allegation of mistreatment involving CNA #6. He said notes were not taken during the meeting and the issue was not processed as a formal grievance. Daily Nursing Schedules for 5/1/16 through 11/4/16 documented CNA #6 was assigned to provide cares to Resident #3, who resided on the 600 Hall, until 5/23/16, when she was assigned to another hall for the rest of that month. The daily nursing schedule, dated 6/1/16, documented CNA #6 was again assigned to the 600 Hall. The daily nursing schedules documented CNA #6 was again assigned to Resident #3 from that time forward, including the night shift of 10/1/16. An In-service Training Record, dated 5/16/16, documented 10 staff were re-educated on providing care to Resident #3. The in-service record documented, (Resident #3) - ensure head is properly positioned and ears are not kinked. Have (Respiratory Therapy) check him after every reposition. Be mindful of head and leg position when repositioning. A 6/6/16 In-service Training Record documented, (Resident #3) - Must be offered to turn and reposition and change brief every 2 hours. The daily nursing schedule for 10/1/16 night shift documented CNA #6 was reassigned from another area of the facility to the 600 Hall when two staff called in sick. The staffing schedule documented CNA #6 was the only night shift CNA assigned to the 600 hall on 10/1/16. The facility's Prevention and Reporting Mistreatment, Neglect, Abuse policy documented, The (facility) is required to report these alleged violations to the Executive Director and DON/designee immediately. 'Immediately' means as soon as possible, but not to exceed 24 hours after discovery of incident .Provide training for all staff who provide care .Training will include .verbal, sexual, physical, and mental abuse, neglect, mistreatment, injuries of unknown source, and misappropriation of property. Suspend identified employee(s) immediately pending outcome of investigation. Additional steps to prevent further potential abuse include .protection from retaliation, staffing changes, follow-up counseling for the resident. Review and investigate .enter details of the investigation into the electronic accident/incident report .report the results to other officials in accordance with State law within 5 working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken. In the case of an employee being investigated for abusing, neglecting, or mistreating a resident, the Executive Director must relieve the individual of their duties without pay until the investigation is complete. NOTIFICATION AND REMOVAL OF IMMEDIATE JEOPARDY: F225 and F226 On 11/3/16 at 6:45 pm, the Interim Administrator and DON were informed these systemic failures placed Resident #3 in Immediate Jeopardy (IJ) of serious harm, impairment, or death based on the facility's failure to identify, investigate, and report the allegation of mistreatment. On 11/14/16, the facility provided an acceptable plan to remove the immediate jeopardy at CFR 483.13 (c) (F225) and CFR 483.13(c)(3) (F226) and alleged removal of the immediacy as of 11/16/16. The systems, procedures, and protocols implemented by the facility to assure removal of the IJ for F225 and F226 were: * Field Director of Education and Training has educated all staff on abuse and neglect policies and procedures to include measures to be taken if abuse/neglect is suspected to include but not limited to immediate suspension of alleged perpetrator, assessing safety of the resident and initiation of investigation and reporting requirements. * Executive Director of Clinical services has educated department head managers on abuse and neglect recognition, identification and the investigative process. * Executive Director of Clinical services has educated department managers on the facility's grievance process to include reviewing grievances within the facility's meeting structure to assure that any potential allegation is thoroughly investigated. This will also provide educational opportunities to assure Department Heads fully comprehend abuse and neglect policy. * Random interviews will be completed by manager of the day and Caring Partners daily of staff to assure understanding of education provided. * Director of Clinical Services and Director of Operations will complete random interviews of staff during facility visits. * DON will write a comprehensive investigation for every allegation of abuse and neglect before investigation will be finalized and will review with the EDCS or the DS. * DCS or EDC½ will review all allegations of abuse and neglect for the next 30 days and monthly thereafter for monitoring of the abuse and neglect investigation process, * Residents will be interviewed weekly on resident treatment by Caring Partners and findings forwarded to Executive Director, Any negative responses will be investigated immediately within the policies and procedures related to abuse and neglect. * Facility's Executive Director of Clinical services was on site on 11/9/16 to 11/11/16 to review systems and implementation. * Facility's Director of Clinical Sårvices was on site on 11/4/16 to 11/10/16 to review systems and implementation, * Facility's Field Director of Education and Training was on site l 1/4/16 to 11/11/16 to provide in-service training to staff * Executive Director with oversight by the EDCS and/or DCS will continue monitoring implementation of the facility's abuse and neglect policies and procedures. On 11/17/16, an on-site revisit was conducted to confirm the immediate jeopardy had been removed. The on-site team confirmed the facility had removed the immediacy as of 11/16/16. 2. Resident #23 was admitted to the facility on [DATE], with multiple diagnoses, which included anxiety and depression. A Social Service Progress Note, dated 5/5/16, documented Resident #23 was cognitively intact. The quarterly MDS assessment, dated 7/13/16, documented Resident #23 was able to make herself understood, could understand others, and was cognitively intact. An Incident Summary, dated 7/22/16, documented that a male resident, whose care plan stated he was to have 1:1 supervision, touched Resident #23's face, and then slid his hand down to her chest before staff could intervene. Resident #23 was upset from the incident and denied physical injury but was emotionally upset from the incident. A Reporter Statement, dated 7/22/16 at 8:50 am, documented Resident #23 called for RN #1 to come in to her room. When she entered the room Resident #23 burst into tears and stated, I was just molested. Resident #24 across the hall came into my room and touched me inappropriately. He patted my head then moved his hands down to my breasts. I tried to stop him and (Hospitality Aide #1-Resident #24's 1:1) tried to get him out of my room. Nurses' Notes, dated 7/22/16 at 8:50 am, documented that Resident #23 reported to staff that a male resident pushed her wheelchair to her room, ran his hands over her head, down her shoulders, and to her breast. She stated that this brought up very bad memories from years ago. Resident #23 was in bed hugging her stuffed animal, as she spoke she began to cry. A Psychologist note, dated 7/22/16 at 3:35 pm, documented that Resident #23 was upset because one of the male residents took liberties with her that morning and it brought up memories of a past sexual abuse. Nurses' Notes, dated 7/22/16 at night, documented that Resident #23 had a resident-to-resident altercation initiated by a male resident, she had complaints of [MEDICAL CONDITION] (post-traumatic stress disorder) from a past experience, that the staff would continue to monitor, and that there were no signs or symptoms of physical injury. Nurses' Notes, dated 7/24/16 at night, documented that Resident #23 had been talking about the assault and how no one seemed concerned. Nurses' Notes, dated 7/25/16 at 3:30 am, documented that Resident #23 was in bed throughout most of the shift except to smoke, and there were no signs or symptoms of physical injury related to the altercation. Nurses' Notes, dated 7/26-7/28/16, had no documentation of the sexual assault by a male resident. Social Services Progress Notes had no documentation of the sexual assault, or how Resident #23 was coping with the issue. The facility's procedure for incident investigation, 1.2.10 Section A, effective July 2015, documented that the following would be included in an investigation: * Document after an accident for a minimum of 72 hours in the resident medical record. * Interviewing alleged victim and witness(es). * Interviewing accused individual. * Interviewing other residents to determine if they have been abused or mistreated. An Incident Summary, dated 7/22/16, documented there was a resident statement of what happened written by Resident #24, and a witness statement by Hospitality Aid #1 (Resident #24's 1:1), neither of these statements were included in the Incident Report. There were also no statements or interviews from other staff members or other residents. On 11/1/16 at 10:30 am, in Resident Council meeting, Resident #23 stated she would like to talk to surveyors about a sexual assault that happened to her. On 11/3/16 at 8:30 am, Resident #23 stated that in early summer there was a male resident across the hall, who was to be on 1:1 supervision, who pushed her wheelchair, with her in it, into her room. He then touched her head, shoulders, and continued down to grab her breast. She called out for help and (Resident #24's 1:1) tried to get him out of her room. She started crying and thought that was why the Resident #24 left her room. She stated she was still upset because it brought up memories of a previous sexual assault that happened years prior. She called in a nurse who took her down to the administrator's office. She stated she believed they transported the accused out of the facility within 24 hours. On 11/3/16 at 2:45 pm, the investigation report was requested from the DON as it was not available in the monthly incident reports. The DON stated he would print it out. At 4:35 pm the report was again requested. The DON provided the incident report. While the report included a statement from Resident #23, it did not contain information from the Resident #23 related to where Resident #24's1:1 staff was at the time of the incident, statements from other residents and staff who may have been in the area, or a statement from the staff member providing 1:1 supervision. 3. Resident #14 was admitted to the facility in May 2014 and readmitted in June 2015 with multiple diagnoses, including [MEDICAL CONDITION] arthritis. The quarterly MDS assessment, dated 9/18/16, documented Resident #14 understood- and was understood by others; had adequate hearing and vision; had moderate cognitive impairment; needed extensive 2-staff assistance for bed mobility/dressing/toileting/hygiene; required required the total assistance of at least 2 staff for transfers/bathing; had limited ROM in both upper and both lower extremities; and had skin tears (ST). Resident #14's Skin Integrity Assessment: Prevention and Treatment Care Plan documented a ST to the right upper arm on 9/8/16, and a bath blanket between the sling and Resident #14, was added as an intervention. Another care planned intervention, undated, was a sheet between Resident #14 and the Hoyer mechanical lift sling. On 11/4/16 at 9:30 am, Resident #14 was observed in bed and a large dark bluish purple and red bruise was noted on her right arm/elbow. The bruised area was covered with a transparent dressing and extended about 3 inches above the elbow and 2-to-3 inches below the elbow, and 2-to-3 inches in front of the elbow. The back of the elbow was not visualized as Resident #14 said it was too painful to move it. With Resident #14's permission, another resident, who asked to remain anonymous, joined the conversation and said every time staff used the Hoyer lift to get Resident #14 up the resident gets an injury. The anonymous resident said Resident #14's right arm/elbow injury occurred about 2 weeks ago when 2 CNAs got her up for a shower. The anonymous resident said Resident #14 refuses to get up with the Hoyer now, to which Resident #14 added, It hurts. The anonymous resident said Resident #14 used to get out of bed for showers twice a week and doctor appointments, but now she gets a bed bath. A Hoyer lift sling was observed on a chair near Resident #14's bed. A 9/7/16 Occurrence Report documented Resident #14 sustained a 3.5 cm by 4.5 cm ST to the right elbow when staff removed a Hoyer sling from under her in bed after a shower. The upper edge of the ST was reapproximated but the lower aspect could not be reapproximated and a transparent dressing was applied. A 9/12/16 Follow up Report to the 9/7/16 Occurrence Report documented the care plan was revised and staff were educated to place a bath blanket between Resident #14 and the shower sling. No other Occurrence Reports for September, October or November 2016 were found for Resident #14. Resident #14's PNs, dated 8/3/16 to 11/4/16, included documentation of the right elbow ST on 9/7/16 and resolution of the ST on 10/19/16. The 10/19/16 entry did not include bruising at the right elbow and there were no other entries about bruises or injuries. On 11/4/16 at 4:10 pm, RN #2, an RCM, said Resident #14's skin was very fragile and that a right elbow skin tear had resolved on 10/19/16. RN #2 said she was not aware of current bruising to Resident #14's right arm/elbow. On 11/4/16 at 4:15 pm, RN #2 accompanied the surveyor to Resident #14's room, where she was observed in bed with her spouse and a female visitor in the room and the Hoyer sling still on the chair. As RN #2 looked at the resident's right arm/elbow, the spouse stated, Every time they get her out of bed that sling causes an injury. Immediately afterward, RN #2 reviewed Resident #14's September and October 2016 MARs and TARs and said that bruising was not monitored after the right elbow ST healed, but if there had been bruising it was not like that. The RN said the transparent dressing over the right arm/elbow bruise was a treatment, but there was no documentation of the treatment. RN #2 said Resident #14 arose from bed only for showers and doctor appointments and her last doctor's appointment was 10/26/16. RN #2 also reviewed Bath Type Detail Reports, which documented Resident #14 was showered on 10/1/16, 10/4/16, 10/11/16, 10/15/16, 10/18/16 and 10/29/16 and received bed baths on 10/22/16 and 11/1/16. RN #2 said no new injuries had been reported to her, but that she would begin an investigation. Resident #14's September, October and November 2016 TARs included areas to document Weekly Skin Assessments with - to indicate no new areas and a + to indicate new area observed. A staff person's initials and - were documented weekly in September and on 10/5/16, 10/12/16, 10/19/16 and 11/2/16. However, on 10/26/16 the initials only were documented and the space to document - or + was blank. There was no documented evidence when Resident #14's right arm/elbow injury occurred, that staff were aware of the bruise, or that the injury of uncertain origin had been investigated to rule out potential abuse. 4. Resident #20's 4/22/16 MDS assessment documented he was feeling down, depressed, or hopeless; had difficulty falling or staying asleep, or slept too much; experienced a poor appetite or overate; felt bad about himself or that he was a failure or had let himself or family down; and had trouble concentrating on things, such as reading the newspaper or watching television. Resident #20 was assessed with [REDACTED]. On 11/3/16 at 4:25 pm, the DON provided a sign-out sheet for Resident #20 dated for 4/24/16 through 8/6/16; the sign-out sheet did not include the resident's signature that he had signed-out of the facility during that period. An undated and unsigned document titled Missing Person Summary documented, (Resident #20) an alert and oriented resident with .an active order to leave the facility left the faciity on [DATE]. He was last seen at approximately (8:30 pm) and noted to not return at (9:00 pm). The resident was noted to not use the proper procedure to sign out in the resident sign out log. A missing person action plan was initiated at (9:00 pm). An EDM (Emergency Department Medical) Record from the local hospital, dated 10/27/16, documented Resident #20 arrived in the emergency department at 9:31 am with multiple complaints. The report documented, (Resident #20 was) a missing person since (10/25/16). (Resident #20) found this (morning) wet and shivering not too far from (facility name). The report stated Resident #20 received intravenous fluids and described the resident as in wet clothes and shaking (and) non verbal to staff. The report documented Resident #20 had been assessed with [REDACTED]. The facility's Missing Person Policy documented, The Executive Director is responsible for follow-up of the incident, including any further reporting to state agencies .and completing and submitting of a detailed incident report. There was no evidence provided by the facility, nor found in the state agency office, that the incident was reported or fully investigated.

Based on record review, policy review, observation, and resident, family member, and staff interview, it was determined the facility failed to follow its own abuse prevention policies and procedures to ensure allegations of mistreatment, elopement, and injury of unknown origin were identified, investigated, and/or reported for 4 of 24 sampled residents (#3, #14, #20, and #23). This deficient practice placed Resident #3 in Immediate Jeopardy (IJ) for serious harm, impairment, or death. Specifically, Resident #3 alleged he was mistreated by CNA #6 who was allowed to provide cares for his roommate for 5 months following the allegation, which was neither reported nor investigated by the facility. Resident #3 was in Immediate Jeopardy for repeat instances of mistreatment and continued to experience anxiety when the alleged perpetrator was allowed to continue assisting with cares for his roommate. Resident #23 was also harmed when she was sexually assaulted by Resident #24, whose care plan stated he was to receive 1:1 supervision. A thorough investigation of the incident was not completed. Additionally, Resident #14 presented with significant bruising of unknown origin that was neither reported nor investigated in a timely manner by the facility. This deficient practice placed Resident #14 at risk of potential abuse as the source of her injuries had not been investigated. The facility failed to investigate a missing resident (Resident #20), who was not located until he was admitted to a hospital approximately 36 hours later with [DIAGNOSES REDACTED]. The facility failed to investigate this elopement as a possible case of neglect or address supervision concerns for other residents in the facility who were also at risk of elopement. Findings include: The facility's Prevention and Reporting: Resident Mistreatment, Neglect, Abuse Policy and Procedure, dated October 2016, documented, The (facility) prohibits the mistreatment, neglect, and abuse of residents .by anyone including staff, family, friends, et. The (facility) has designed and implemented processes, which strive to ensure the prevention and reporting of resident abuse, neglect, mistreatment .All allegations that meet the definition of abuse and substantiated violations will be reported to state agencies and to all other agencies including the local law enforcement, elder abuse agencies, and Adult Protective Services, as required. The (facility) takes all necessary corrective actions depending on the result of the investigation. This policy was not followed. Examples include: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS assessment, dated 5/16/16, documented Resident #3 was cognitively intact, and totally dependent on at least two staff for all activities of daily living due to paralysis below the neck from a sudden onset of [DIAGNOSES REDACTED], a rare [DIAGNOSES REDACTED] disorder in which the immune system attacks healthy nerve cells in the peripheral nervous system leading to paralysis. On 11/2/16 at 4:00 pm, Resident #3's family member stated, Right after we got here we had a problem. A night shift CNA (#6) was rough with him. She tried to turn him by herself and when she left the room his head, arms, and legs (were) hanging off of the bed. He uses his head to press against the call light and he was unable to use his call light. He told me that he was left in that position for several hours and unable to ask for help. He told me a nurse came into the room several hours later and with the help of another CNA repositioned him correctly. I wrote a note about it and gave it to the Unit Manager who said she would write it up. I never heard what happened, but she (CNA #6) didn't come back to care for him again. On 11/2/16 at 4:00 pm, Resident #3, when asked if he felt CNA #6 was rough with him, nodded his head, Yes. The family member stated, The Unit Manager asked him if it would be alright if she brought (CNA #6) into the room to teach her how to reposition him. He told her, 'No,' by moving his head from side to side. She is the only one (staff) he has a problem with and he insisted that she not come back into the room. During this conversation with the family member on 11/2/16 at 4:00 pm, Resident #3, who was unable to speak due to a [MEDICAL CONDITION] providing oxygen via ventilator, motioned for a communication board. The resident then nodded his head back and forth or side-to-side as his family member pointed out letters that eventually spelled, Tell her what happened. The family member stated, On 10/2/16 he told me something that happened the night before on the night shift. He said there were only two people on the shift and one of them was (CNA #6). He said a nurse came into the room and told him she couldn't reposition him by herself and the other CNA on duty was (CNA #6), who was not allowed in the room. He wasn't repositioned or changed (when incontinent) all night. The family member, who kept a journal in which she documented what Resident #3 reported to her, contained the following entry: 10/2/16 - Arrive 8:35 leave 9:45 couldn't get changed during night-called for help-because other aide was one he had problems with. She refused to come in, he wouldn't have her. The family member stated, I told (the DON) and he said, We have trouble finding CNAs that are comfortable with vent patients. On 11/3/16 at 9:30 am, UM #1 stated, I remember a conversation I had with (Resident #3 and his family member) and I took it to (the DON); I don't know if they investigated it or not. (Resident #3 and his family member) said they did not want (CNA #6) to go back into the room. I don't recall getting any written note from the family member. I might have been the one who requested that (CNA #6) not go back into the room, I just can't recall and I don't have anything in writing. On 11/3/16 at 11:00 am, the DON said he was aware CNA #6 was not allowed into Resident #3's room to provide care, but did not know the reason. The DON stated he scheduled CNA care assignments and that he assigned CNA #6 to an area of the facility where she would not come into contact with Resident #3 or his family member. On 11/3/16 at 12:20 pm, UM #1 stated she did not initiate an investigation when Resident #3's family member spoke to her several months previous. UM #1 stated, The only nurse aide that (Resident #3) and his family member had a problem with was (CNA #6). I counseled (CNA #6), but I didn't write anything up. I talked to the DON and we tried to brainstorm . On 11/3/16 at 12:30 pm, LN #2 said she worked the night shift and knew CNA #6 was not allowed to provide care to Resident #3. LN #2 stated, When (CNA #6) works .we have to watch her call lights because she is not allowed to care for (Resident #3). (CNA #6) trades with someone else on duty when it comes to (Resident #3's) care; everyone knows she can't go in there. On 11/3/16 at 12:40 pm, Resident #3's family member stated she met with the Administrator and DON on 10/10/16, at which time she stated she did not want CNA #6 in the resident's room. At the time of this interview, Resident #3 stated his participation in Speech Therapy enabled him to now speak. Resident #3 stated, She's the only one I had trouble with. At that time I had no strength in my neck and I couldn't position my head. She left me on my bedsore for hours and I couldn't use my call button. I couldn't explain to them then what I needed and they didn't have time to use the communication sheet. When asked if he felt he had been mistreated by CNA #6, Resident #3 said, Yes. On 11/3/16 at 12:45 pm, CNA #4 said she knew CNA #6 was not allowed in Resident #3's room and stated, I heard (CNA #6) was being too rough when changing him. A couple of days ago (CNA #6) worked that night and the resident and his (family member) said he wasn't changed or touched all night because (CNA #6) could not go in there and they were short (staffed) that night. On 11/3/16 at 1:00 pm, the Administrator stated he recalled the meeting with Resident #3's family member on 10/10/16, however, he said he was not aware of an allegation of mistreatment involving CNA #6. He said notes were not taken during the meeting and the issue was not processed as a formal grievance. Daily Nursing Schedules for 5/1/16 through 11/4/16 documented CNA #6 was assigned to provide cares to Resident #3, who resided on the 600 Hall, until 5/23/16, when she was assigned to another hall for the rest of that month. The daily nursing schedule, dated 6/1/16, documented CNA #6 was again assigned to the 600 Hall. The daily nursing schedules documented CNA #6 was again assigned to Resident #3 from that time forward, including the night shift of 10/1/16. An In-service Training Record, dated 5/16/16, documented 10 staff were re-educated on providing care to Resident #3. The in-service record documented, (Resident #3) - ensure head is properly positioned and ears are not kinked. Have (Respiratory Therapy) check him after every reposition. Be mindful of head and leg position when repositioning. A 6/6/16 In-service Training Record documented, (Resident #3) - Must be offered to turn and reposition and change brief every 2 hours. The daily nursing schedule for 10/1/16 night shift documented CNA #6 was reassigned from another area of the facility to the 600 Hall when two staff called in sick. The staffing schedule documented CNA #6 was the only night shift CNA assigned to the 600 hall on 10/1/16. The facility's Prevention and Reporting Mistreatment, Neglect, Abuse policy documented, The (facility) is required to report these alleged violations to the Executive Director and DON/designee immediately. 'Immediately' means as soon as possible, but not to exceed 24 hours after discovery of incident .Provide training for all staff who provide care .Training will include .verbal, sexual, physical, and mental abuse, neglect, mistreatment, injuries of unknown source, and misappropriation of property. Suspend identified employee(s) immediately pending outcome of investigation. Additional steps to prevent further potential abuse include .protection from retaliation, staffing changes, follow-up counseling for the resident. Review and investigate .enter details of the investigation into the electronic accident/incident report .report the results to other officials in accordance with State law within 5 working days of the incident, and if the alleged violation is verified, appropriate corrective action must be taken. In the case of an employee being investigated for abusing, neglecting, or mistreating a resident, the Executive Director must relieve the individual of their duties without pay until the investigation is complete. NOTIFICATION AND REMOVAL OF IMMEDIATE JEOPARDY: F225 and F226 On 11/3/16 at 6:45 pm, the Interim Administrator and DON were informed these systemic failures placed Resident #3 in Immediate Jeopardy (IJ) of serious harm, impairment, or death based on the facility's failure to identify, investigate, and report the allegation of mistreatment. On 11/14/16, the facility provided an acceptable plan to remove the immediacy at CFR 483.13 (c) (F225) and CFR 483.13(c)(3) (F226) and alleged removal of the immediacy as of 11/16/16. Refer to F225 for details of the plan On 11/17/16, an on-site revisit was conducted to confirm the immediate jeopardy had been removed. The on-site team confirmed the facility had removed the immediacy as of 11/16/16. 2. Resident #23 was admitted to the facility on [DATE], with multiple diagnoses, which included anxiety and depression. A Social Service Progress Note, dated 5/5/16, documented Resident #23 was cognitively intact. The quarterly MDS assessment, dated 7/13/16, documented Resident #23 was able to make herself understood, could understand others, and was cognitively intact. An Incident Summary, dated 7/22/16, documented that a male resident, whose care plan stated he was to have 1:1 supervision, touched Resident #23's face, and then slid his hand down to her chest before staff could intervene. Resident #23 was upset from the incident and denied physical injury but was emotionally upset from the incident. A Reporter Statement, dated 7/22/16 at 8:50 am, documented Resident #23 called for RN #1 to come in to her room. When she entered the room Resident #23 burst into tears and stated, I was just molested. Resident #24 across the hall came into my room and touched me inappropriately. He patted my head then moved his hands down to my breasts. I tried to stop him and (Hospitality Aide #1-Resident #24's 1:1) tried to get him out of my room. Nurses' Notes, dated 7/22/16 at 8:50 am, documented that Resident #23 reported to staff that a male resident pushed her wheelchair to her room, ran his hands over her head, down her shoulders, and to her breast. She stated that this brought up very bad memories from years ago. Resident #23 was in bed hugging her stuffed animal, as she spoke she began to cry. A Psychologist note, dated 7/22/16 at 3:35 pm, documented that Resident #23 was upset because one of the male residents took liberties with her that morning and it brought up memories of a past sexual abuse. Nurses' Notes, dated 7/22/16 at night, documented that Resident #23 had a resident-to-resident altercation initiated by a male resident, she had complaints of [MEDICAL CONDITION] (post-traumatic stress disorder) from a past experience, that the staff would continue to monitor, and that there were no signs or symptoms of physical injury. Nurses' Notes, dated 7/24/16 at night, documented that Resident #23 had been talking about the assault and how no one seemed concerned. Nurses' Notes, dated 7/25/16 at 3:30 am, documented that Resident #23 was in bed throughout most of the shift except to smoke, and there were no signs or symptoms of physical injury related to the altercation. Nurses' Notes, dated 7/26-7/28/16, had no documentation of the sexual assault by a male resident. Social Services Progress Notes had no documentation of the sexual assault, or how Resident #23 was coping with the issue. The facility's procedure for incident investigation, 1.2.10 Section A, effective July 2015, documented that the following would be included in an investigation: * Document after an accident for a minimum of 72 hours in the resident medical record. * Interviewing alleged victim and witness(es). * Interviewing accused individual. * Interviewing other residents to determine if they have been abused or mistreated. An Incident Summary, dated 7/22/16, documented there was a resident statement of what happened written by Resident #24, and a witness statement by Hospitality Aid #1 (Resident #24's 1:1), neither of these statements were included in the Incident Report. There were also no statements or interviews from other staff members or other residents. On 11/1/16 at 10:30 am, in Resident Council meeting, Resident #23 stated she would like to talk to surveyors about a sexual assault that happened to her. On 11/3/16 at 8:30 am, Resident #23 stated that in early summer there was a male resident across the hall, who was to be on 1:1 supervision, who pushed her wheelchair, with her in it, into her room. He then touched her head, shoulders, and continued down to grab her breast. She called out for help and (Resident #24's 1:1) tried to get him out of her room. She started crying and thought that was why the Resident #24 left her room. She stated she was still upset because it brought up memories of a previous sexual assault that happened years prior. She called in a nurse who took her down to the administrator's office. She stated she believed they transported the accused out of the facility within 24 hours. On 11/3/16 at 2:45 pm, the investigation report was requested from the DON as it was not available in the monthly incident reports. The DON stated he would print it out. At 4:35 pm the report was again requested. The DON provided the incident report. While the report included a statement from Resident #23, it did not contain information from the Resident #23 related to where Resident #24's 1:1 staff was at the time of the incident, statements from other residents or staff who may have been in the area, or a statement from the staff member providing the 1:1 supervision. 3. Resident #14 was admitted to the facility in May 2014 and readmitted in June 2015 with multiple diagnoses, including [MEDICAL CONDITION] arthritis. The quarterly MDS assessment, dated 9/18/16, documented Resident #14 understood, and was understood by others; had adequate hearing and vision; had moderate cognitive impairment; needed extensive 2-staff assistance for bed mobility/dressing/toileting/hygiene; required required the total assistance of at least 2 staff for transfers/bathing; had limited ROM in both upper and both lower extremities; and had skin tears (ST). Resident #14's Skin Integrity Assessment: Prevention and Treatment Care Plan documented a ST to the right upper arm on 9/8/16, and a bath blanket between the sling and Resident #14, was added as an intervention. Another care planned intervention, undated, was a sheet between Resident #14 and the Hoyer mechanical lift sling. On 11/4/16 at 9:30 am, Resident #14 was observed in bed and a large dark bluish purple and red bruise was noted on her right arm/elbow. The bruised area was covered with a transparent dressing and extended about 3 inches above the elbow and 2-to-3 inches below the elbow, and 2-to-3 inches in front of the elbow. The back of the elbow was not visualized as Resident #14 said it was too painful to move it. With Resident #14's permission, another resident, who asked to remain anonymous, joined the conversation and said every time staff used the Hoyer lift to get Resident #14 up the resident gets an injury. The anonymous resident said Resident #14's right arm/elbow injury occurred about 2 weeks ago when 2 CNAs got her up for a shower. The anonymous resident said Resident #14 refuses to get up with the Hoyer now, to which Resident #14 added, It hurts. The anonymous resident said Resident #14 used to get out of bed for showers twice a week and doctor appointments, but now she gets a bed bath. A Hoyer lift sling was observed on a chair near Resident #14's bed. A 9/7/16 Occurrence Report documented Resident #14 sustained a 3.5 cm by 4.5 cm ST to the right elbow when staff removed a Hoyer sling from under the resident in bed after a shower. The upper edge of the ST was reapproximated but the lower aspect could not be reapproximated and a transparent dressing was applied. A 9/12/16 Follow up Report to the 9/7/16 Occurrence Report documented the care plan was revised and staff were educated to place a bath blanket between Resident #14 and the shower sling. No other Occurrence Reports for September, October or November 2016 were found for Resident #14. Resident #14's PNs, dated 8/3/16 to 11/4/16, included documentation of the right elbow ST on 9/7/16 and resolution of the ST on 10/19/16. The 10/19/16 entry did not include bruising at the right elbow and there were no other entries about bruises or injuries. On 11/4/16 at 4:10 pm, RN #2, an RCM, said Resident #14's skin was very fragile and that a right elbow skin tear had resolved on 10/19/16. RN #2 said she was not aware of current bruising to Resident #14's right arm/elbow. On 11/4/16 at 4:15 pm, RN #2 accompanied the surveyor to Resident #14's room, where the resident was observed in bed with her spouse and a female visitor in the room and the Hoyer sling still on the chair. As RN #2 looked at the resident's right arm/elbow, the spouse stated, Every time they get her out of bed that sling causes an injury. Immediately afterward, RN #2 reviewed Resident #14's September and October 2016 MARs and TARs and said that bruising was not monitored after the right elbow ST healed, but if there had been bruising it was not like that. The RN said the transparent dressing over the right arm/elbow bruise was a treatment, but there was no documentation of the treatment. RN #2 said Resident #14 arose from bed only for showers and doctor appointments and her last doctor's appointment was 10/26/16. RN #2 also reviewed Bath Type Detail Reports, which documented Resident #14 was showered on 10/1/16, 10/4/16, 10/11/16, 10/15/16, 10/18/16 and 10/29/16 and received bed baths on 10/22/16 and 11/1/16. RN #2 said no new injuries had been reported to her, but that she would begin an investigation. Resident #14's September, October and November 2016 TARs included areas to document Weekly Skin Assessments with - to indicate no new areas and a + to indicate new area observed. A staff person's initials and - were documented weekly in September and on 10/5/16, 10/12/16, 10/19/16 and 11/2/16. However, on 10/26/16 the initials only were documented and the space to document - or + was blank. There was no documented evidence when Resident #14's right arm/elbow injury occurred, that staff were aware of the bruise, or that the injury of uncertain origin had been investigated to rule out potential abuse. 4. Resident #20's 4/22/16 MDS assessment documented he was feeling down, depressed, or hopeless; had difficulty falling or staying asleep, or slept too much; experienced a poor appetite or overate; felt bad about himself or that he was a failure or had let himself or family down; and had trouble concentrating on things, such as reading the newspaper or watching television. Resident #20 was assessed with [REDACTED]. On 11/3/16 at 4:25 pm, the DON provided a sign-out sheet for Resident #20 dated for 4/24/16 through 8/6/16; the sign-out sheet did not include the resident's signature that he had signed-out of the facility during that period. An undated and unsigned document titled, Missing Person Summary, documented, (Resident #20) an alert and oriented resident with . an active order to leave the facility left the faciity on [DATE]. He was last seen at approximately (8:30 pm) and noted to not return at (9:00 pm). The resident was noted to not use the proper procedure to sign out in the resident sign out log. A missing person action plan was initiated at (9:00 pm). An EDM (Emergency Department Medical) Record from the local hospital, dated 10/27/16, documented Resident #20 arrived in the emergency department at 9:31 am with multiple complaints. The report documented, (Resident #20 was) a missing person since (10/25/16). (Resident #20) found this (morning) wet and shivering not too far from (facility name). The report stated Resident #20 received intravenous fluids and described the resident as in wet clothes and shaking (and) non verbal to staff. The report documented Resident #20 had been assessed with [REDACTED]. The facility's Missing Person Policy documented, The Executive Director is responsible for follow-up of the incident, including any further reporting to state agencies .and completing and submitting of a detailed incident report. There was no evidence provided by the facility, nor found in the state agency office, that the incident was reported or fully investigated. The facility failed to operationalize its policies and procedures related to abuse and neglect.

Based on record review; staff, resident, and family interviews; and policy review, it was determined the facility failed to ensure adequate supervision was provided to prevent 2 of 24 sampled residents (#20 and #24) from physically and sexually assaulting other residents and eloping from the facility. The failure to prevent elopement placed all cognitively impaired and cognitively intact residents who were independently mobile in Immediate Jeopardy of serious impairment, harm, or death. It also resulted in serious harm and impairment to Resident #20. The Immediate Jeopardy was identified to have existed since 10/25/16, when Resident #20, with mental health [DIAGNOSES REDACTED]. Adequate supervision was also not provided for Resident #24, who sexually assaulted Resident #23 in her room when the 1:1 staff physician-ordered and care planned to supervise the resident failed to prevent Resident #24 from sexually assaulting Resident #23. Findings include: 1. A PASRR-MI Evaluation Form (Preadmission Screening for Mental Illness), dated 4/21/16, documented Resident #20 had functional limitations related to interpersonal functioning. The form stated Resident #20 had serious difficulty interacting appropriately and communicating effectively with other persons, had a possible history of altercations, evictions, firing, fear of strangers, avoidance of interpersonal relationships, and social isolation. Resident #20's MDS assessment, dated 4/22/16, documented he was admitted from an acute hospital on [DATE]. The assessment stated Resident #20 was feeling down, depressed, or hopeless, had trouble falling or staying asleep, or slept too much, had poor appetite or overeating, felt bad about himself or that he was a failure or had let himself or family down, and had trouble concentrating on things, such as reading the newspaper or watching television. The MDS also documented Resident #20 had moderate cognitive impairment. A Progress Note, dated 6/20/16, in Resident #20's medical record documented, Per 24 hour report nursing notes resident charted for suicidal thoughts & walking. Resident #20's Mood and Behavior Symptom Assessment Care Plan, last dated August 2016, documented, Potential for side effects related to psychotropic drug use: Seroquel. Diagnosis: [REDACTED]. Disturbed Sleep. Psychotropic drug use: Prozac, Remeron. Major Depression Dependent personality disorder. Repetitive physical movement, Dizziness/Vertigo, Unsteady gait. fell in past 31-180 days. Resident #20's Elopement Plan of Care: Assessment, Prevention, and Management, dated 8/8/16, documented Resident #20, Expresses desire to leave. Impaired Cognition: Major depressive disorder. Independently mobile. Anxious, fearful. The interventions in the care plan documented a wander alert system was initiated but discontinued on 5/6/16. Other interventions included, allow for safe wandering. No other evidence of supervision of Resident #20 could be found in the medical record and the DON was unable to provide evidence of enhanced supervision after the wanderguard was discontinued. During the 3-4 weeks (October 1-October 25) prior to Resident #20 leaving the facility unsupervised, the progress notes documented he was refusing medications and baths, refused to participate in conversations, and exhibited an odd behavior. An untimed progress note, dated 10/25/16, documented, Resident was in room in bed @ (at) start of shift. He left his room before dinner, did not sign out. Resident is (unable to interpret) in*out of facility but had not returned by 2100 (9:00 pm). Resident #20's MDS assessment, with a reference date of 10/24/16, documented he experienced little interest or pleasure in doing things, had trouble falling or staying asleep, or slept too much, was feeling tired or had little energy, poor appetite or overeating, felt bad about himself-or felt he was a failure or had let himself or family down and had trouble concentrating on things, such as reading the newspaper or watching television, 7-11 days during the 14 day lookback period. The MDS also documented Resident #20 had moderate cognitive impairment. An MDS assessment, dated 10/25/16, was completed to modify an existing record. The changes on this assessment were to clarify that Resident #20 was admitted on [DATE] from a psychiatric hospital, instead of an acute hospital as noted on his 4/22/16 admission MDS assessment, and to add a [DIAGNOSES REDACTED]. The Emergency Department Medical Record, from the local hospital, dated 10/27/16, documented Resident #20 arrived in the emergency department at 9:31 pm, with, Multiple Complaints. The report documented, Pt a missing person since Tues night. Pt resident at (name of facility). Pt found this PM wet and shivering not to far from (facility name). The report stated Resident #20 received intravenous fluids and described him as, Pt in wet cloths and shaking pt none verbal to staff. The report listed problems, Altered mental status (Acute), Catatonia (Acute), Dehydration (Acute), Exposure to environmental cold (Acute), Acute hyponatremia (Acute), Confusion (Acute), Dehydration (Acute), Depression (Acute), Paranoia (Acute), Vomiting (Acute). Another Emergency Department Record, dated 10/27/16, documented, He (Resident #20) was reported missing 2 nights ago from (facility name). The patient is found to have scattered abrasions of the back and extremities, he appears cold and disheveled, fingers and toes appear whitish and cold with no signs of frostbite, he has petechiae (small red or purple spots caused by bleeding into the skin) of the shins, and he follows commands. On re-evaluation, the patient is noted to take exaggerated breaths and grimaces in addition to not significantly moving his body, which is consistent with catatonia and his previous history of the same during his last hospitalization . Laboratory results show hyperglycemia, hypochloremia (electrolyte disturbance), low CO2, and elevated WBC, BUN, and AST levels. Urine dip shows elevated ketones, small bilirubin, and moderate blood. Chest X ray shows mild bronchovascular crowding at the lung bases likely related to atelectasis (collapsed or closed lung). Subtle infiltrate at the right lung base not entirely excluded. Patient was administered 2.5 L (liters) saline IV while in the department. Earlier in the day on 11/03/16, the DNS stated there was no investigation or report of Resident #20 ever leaving the facility unsupervised. However, the same day, at 4:20 pm, the DNS stated that the resident did sign himself out at times, and produced documents regarding Resident #20 being out of the facility unsupervised. A sign-out document with Resident #20's name at the top, had no signature that he signed himself out of the facility. The first entry on the sign-out form was dated 4/24/16 and the last was dated 8/6/16. An undated and unsigned document titled, Missing Person Summary, was provided. It documented, (Resident #20) an alert and oriented resident with a BIMS>12 per MDS assessment and an active order to leave the facility left the faciity on [DATE]. He was last seen at approximately 2030 (8:30 pm) and noted to not return at 2100 (9:00 pm). The resident was noted to not use the proper procedure to sign out in the resident sign out log. A missing person action plan was initiated at 2100. An additional document, with one typed paragraph, dated 10/25/16, signed by the DNS and dated 10/26/16, stated, (Resident #20) is a (Resident #20's age) year old male. Independently mobile with a BIMS of 13 on his last MDS. Was last seen at approximately 2030 outside in the employee parking lot. Not an unusual occurrence for the resident. He is alert and oriented. He will walk to the store or other local places to get food or other items from time to time. He was reported missing to myself via phone call at 2116 (9:16 pm). A phone interview was conducted with Resident #20's family member on 11/4/16 at 10:00 am. Resident #20's family member stated she was awakened by police at her door early in the morning on 10/26/16. Resident #20's family member said she had silenced her phone before bedtime on 10/25/16 and reported she had missed calls from the police and the facility stating that (Resident #20) had left the facility at approximately 8:00 pm on 10/25/16, unsupervised and his whereabouts continued to be unknown. Resident #20's family member stated the resident did not have a car and relied on herself and (a friend) for transportation, which consisted of occasional doctor appointments. Resident #20's family member was aware the resident had initially had a Wanderguard and questioned its removal per staff as she believed Resident #20's mental health had declined since being admitted to the facility. Resident #20's family member and (a friend) drove around town and visited several 24 hour stores in hopes of finding him. The family member stated that on 10/27/16 at approximately 9:30 am, she was notified that Resident #20 was located on Northwest Boulevard, south of the 95 overpass. She said police had taken Resident #20 to the local hospital. Resident #20's family member reported being very frightened since the resident had attempted suicide 8 years ago and had received many inpatient events since that time with the most recent at a state mental facility immediately before arriving at this facility. Resident #20 was taken to the local hospital the day he was found (10/27/16) and remained there throughout the survey. NOTIFICATION AND REMOVAL OF IMMEDIATE JEOPARDY: F323 On 11/4/16, at 5:15 pm, the facility's Interim Administrator, Director of Nursing (DON), and Director of Operations were notified that the failure to provide adequate supervision to prevent elopement for Resident #20, placed other cognitively intact and cognitively impaired, independently mobile residents in Immediate Jeopardy. On 11/15/16, the facility provided an acceptable plan to remove the immediacy at CFR 483.25 (H) and alleged removal of the immediacy as of 11/16/16. The systems, procedures, and protocols implemented by the facility to assure removal of the IJ for F323 were: * Residents with the ability to leave center independently have been re-assessed to ensure appropriate cognitive capabilities, mobility status and that physician orders [REDACTED]. * Field Education and Training Director has educated staff on Leave of Absence policy and procedure which includes but is not limited to staff actions required if resident does not return as scheduled, medication management and appropriate attire for outings. * Residents assessed as safe to leave center have been educated on the leave of absence policy and procedure. * Residents will be assessed upon admission, quarterly and with significant changes for the ability to leave center independently during the facility's clinical meetings and comprehensive care plan review meeting. * Residents who are independently mobile and cognitively impaired have been re-assessed for elopement risk and care plans and care delivery guides reviewed for appropriate interventions. * Field Education and Training Director have educated the staff on policies and procedures related to elopement management to include interventions and management of wanderguards. * Residents will be assessed upon admission, quarterly and with significant changes for elopement risks during the facility's clinical meetings and comprehensive care plan review meeting. On 11/17/16, an on-site revisit was conducted to confirm the immediate jeopardy had been removed. The on-site team confirmed the facility had removed the immediacy as of 11/16/16. 2. Resident #24 was admitted to facility on 7/5/16, with multiple [DIAGNOSES REDACTED]. Nurses' Notes, dated 7/7/16 on the evening shift, documented Resident #24 was combative, kicked at walls, threw items, and nearly hit another resident. Nurse' Notes, dated 7/11/16 on the night shift, documented Resident #24 had a 1:1 caregiver all night due to behaviors and eloping. The 14 day MDS assessment, dated 7/18/16, documented Resident #24 was having physical and verbal behaviors. A Comprehensive Care Plan Review Summary, that was not dated, documented Resident #24 had mood issues, and had a BIMS score of 0; indicating Resident #24 was cognitively impaired. A Safety Device Care Plan, initiated 6/6/16, documented Resident #24 had impaired cognition, was exit seeking, and had a Wanderguard ankle bracelet in place. A Mood and Behavior Symptom Assessment Care Plan, initiated 7/2016, documented Resident #24 was verbally abusive, physically abusive, disrobed in public, entered other residents rooms, and slept in other beds. An Elopement Care Plan, dated 7/6/16, documented Resident #24 was independently mobile, and initiated 7/12/16, an intervention for 1:1 observation. A Physician Order, dated 7/8/16, documented an order for [REDACTED]. A Psychiatric consult note, dated 7/11/16 at 4:00 pm, documented Resident #24's medication regime did not appear to have been effective in reducing his agitation, restlessness, confusion, and hyper-sexuality. A Physician Order, dated 7/12/16, documented an order for [REDACTED]. Nurses' Notes, dated 7/16/18 at 2:15 am, documented Resident #24 was on 1:1 supervision due to behaviors, that he had shoved a wheel chair with a resident sitting in it, kicked at the wall, and hit the door alarm. Nurses' Notes, dated 7/16/16 on the day shift, documented Resident #24 was touching inappropriately and had been updated to 2 person cares at all times. A Physician Order, dated 7/18/16, documented an increase in Seroquel to 50 mg, due to Resident #24 being combative, multiple threats to the 1:1 caregiver, physical outburst resulting in broken equipment, and that he had shoved a wheelchair with another resident in it. Nurses' Notes, dated 7/19/16 (no time given), documented Resident #24 was given an extra dose of Ativan for anxiety, that he was throwing a wheelchair, pulling phone and bed cord out of the wall and bed, was crying and yelling, that Ativan was only slightly effective, and that he was switched to a male 1:1 caregiver. Nurses' Notes, dated 7/19/16 at night, documented that Resident #24 was on a 1:1 supervision for recent displays of unpredictable behaviors. Nurses' Notes, dated 7/21/16 at 10:00 pm, documented that Resident #24 was on a 1:1 supervision for his pattern of extreme behaviors including threats of violence. A Physician Order, dated 7/19/16, documented a change in his Seroquel to 25 mg in the morning and 50 mg at bedtime. A Physician Order, dated 7/22/16 at 5:30 am, documented an increase in his Ativan (anti-anxiety medication) dose for anxiety and agitation. Nurses' Notes, dated 7/22/16 (no time given), documented that Resident #24 grabbed a female resident and shook her, the physician was notified, a dose of Seroquel was given, and Resident #24 was sent out to the emergency room . A Physician Order, dated 7/22/16, documented an extra dose of Seroquel 100 mg for agitation, and an order to send him to the emergency room . An Incident Summary, dated 7/22/16, documented that a male resident, who was care planned to have 1:1 supervision with him, sexually assaulted Resident #23. The facility's Resident Supervision Procedure, effective July 2015, documented the following: * That the center strives to provide the appropriate level of supervision, ensure an immediate and optimal level of safety and outcome for the resident .will continually evaluate the level of supervision needed through assessment and observation of the resident's cognitive, behavioral, medical or other conditions that put them at risk to self or others. * The staff will document supervision using the 24 Hour Resident Flow Record * Transfer supervision checks from one staff member to another by signing and initialing the 24 Hour Resident Flow Record. * The assigned staff member must stay within close physical proximity, example one to two arm lengths of the resident at all times and see the resident at all times. Observations will be documented every 15 minutes using the 24 Hour Resident Flow Record. On 11/4/16 at 4:35 pm, when asked for documentation that 1:1 supervision was provided as physician ordered and care planned, the DON stated, We don't do that. When asked how the facility ensured 1:1 supervision actually took place, the DON stated he knew it took place because the 1:1 was assigned. The facility failed to ensure Resident #24 received the level of supervision necessary to prevent him from sexually assaulting Resident #23, shoving a wheelchair with a resident in it, and grabbing and shaking a female resident.

Based on observation, staff and family member interview, and record review, it was determined the facility failed to provide range of motion services to prevent avoidable reduction in range of motion, failed to apply a hand splint and rolled wash cloths, and/or failed to provide restorative care for 3 of 24 sampled residents (#1, #3, and #12). This failure resulted in harm to Resident #3 when he experienced foot drop and further decline in ROM. It also placed Residents #1 and #12 at risk of decline in ROM due to lack of consistent implementation of restorative interventions. Findings include: 1. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #3's admission MDS assessment, completed on 5/16/16, documented he had no cognitive impairment, required total assistance with all activities of daily living due to the paralysis of all four limbs and below the neck caused by the sudden onset of [DIAGNOSES REDACTED] (a rare but serious [DIAGNOSES REDACTED] disorder in which the immune system attacks healthy nerve cells in the peripheral nervous system leading to paralysis). The MDS stated Resident #3 was totally dependent on staff with two-person physical assistance. The MDS assessment further stated Resident #3 had functional limitation in range of motion in his upper extremities (shoulder, elbow, wrist, hand-impairment on both sides), and lower extremities (hip, knee, ankle, foot) impairment on both sides. On 11/2/16 at 9:00 am, a family member stated s/he provided range of motion services to Resident #3. Resident #3 was observed in bed lying on his back. Both of Residents 3's feet were in cushioned boots. Resident #3's feet were dropped at the ankle and his knees were touching. (Foot drop is a general term for difficulty lifting the front part of the foot. When there is foot drop, the foot may be dragged on the ground when walking. Foot drop is a sign of an underlying neurological, muscular or anatomical problem. (Mayo Clinic Staff 2016) The family member stated Resident #3 was unable to lift the front part of the foot due to weakness and paralysis. The family member stated, s/he brought a hard boot in that prevented Resident #3's feet from dropping, but therapy said not to use it because it could cause skin breakdown. A Physical Therapy (PT) initial Evaluation, dated 5/10/16, documented, [DIAGNOSES REDACTED]. The therapy evaluation documented, Short-term goals, establish range of motion program to prevent contractures with training of family and staff. Long-term goals, Client will demonstrate return of trunk/extremity mobility through neuromuscular stimulation techniques applied, target date 6/14/16. The evaluation included, Cognition-Client is cognitively aware and able to fully field entire body, however unable to move voluntarily except for some face and neck. A Physical Therapy Treatment Encounter Note (TEN), dated 5/19/16, stated, Response to Session interventions: Pt communicated he was able to feel the nerves in his legs and can communicate through head nods and shakes and an alphabetical piece of paper by using rows and head nods. The TEN, dated 6/20/16, documented, Response to Session interventions: The patient compliant with skilled interventions. A TEN, dated 6/22/16, stated, Client and his wife spoken to at bedside regarding skilled PT plateauing and need to establish restorative nursing program. Clients wife and client expressed understanding that any additional progression to be monitored, with therapy notified to assess for restart of skilled intervention in the future. Discussed and established restorative nursing program with guidelines. The Restorative Program Summary Report documented the restorative start date was 7/10/16. The report included, Passive ROM (Range Of Motion) Program: FLOOR CNA (Certified Nursing Assistant). GOALS: To help maintain current level of function. PLAN: Passive range of motion to all extremities, flexion and extension to wrist, elbows, shoulders, ankles, knees, hips for a minimum of 15 min/day up to 6 days/week. Notify licensed nurse of refusals, pain, or intolerance. The restorative program summary report, dated 7/1/16 through 11/3/16, showed there were a total of 6 documented refusals by Resident #3. The summary report stated that ROM services were provided by the facility restorative program an average of three times per week with the week of 8/21/16 through 8/27/16 having provided ROM once on 8/21/16. There was no documented refusal by Resident #3 during that week. On 11/4/16 at 10:00 am, during an interview with LN #5, who stated she was the facility restorative nurse, LN #5 stated there were a total of two restorative CNAs for the facility. LN #5 stated the goal was to provide each resident restorative nursing 6 times a week, but that sometimes they did not have time. She said the CNAs on the floor were to do ROM during cares. LN #5 stated there were 49 residents on the restorative program and 43 of them were on range of motion programs. She stated the 600 Hall where residents with ventilator's resided, had the highest number of residents on the restoration program. LN #5 said the CNAs on the 600 hall were to do ROM. She stated there was one resident who could get out of bed and come to the gym and have treatment completed there. On 11/4/16 at 10:15 am, CNA #7, a restorative aide, stated there were too many residents who need restorative and not enough restorative aides. CNA #7 stated, they talked to the DON a couple of months ago and asked for a third restorative aide, and the DON said he was working on it. On 11/4/16 at 9:15 am, during an interview with PT #1, she said Resident #3 was well-known by the therapist and she had provided services to him since his admission to the facility. PT #1 stated that she had no referral to evaluate Resident #3 for decline in ROM or foot drop. PT #1 went to Resident #3's room to do a screen for therapy services. PT #1 said, He has foot drop now, he did not have that when he came here, I'm sorry about that. The harder boots did not work and were causing him to be at risk for skin breakdown. We will get orders today for the screen, there have been a lot of changes with him and we will pick him back up. PT #1 provided passive range of motion during the observation with Resident #3 and stated, There are changes in the hips and the knees are together, this is from the wedge cushions under his hips to keep pressure off the wound on his sacral area. He has lost some range in his left shoulder too. Thank you for alerting me. 2. Resident #12's record was reviewed on 11/4/16 at 10:30 am. Resident #12's [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 10/25/16, documented Resident #12 had limitation in range of motion to bilateral upper and lower extremities. A physician's orders [REDACTED].RA (restorative aide) to report any redness/ impairment to LN (licensed nurse)/ RCM (resident care manager) of splinting daily. See restorative plan. Resident #12 was observed on 11/3/16 at 10:35 am, 11/4/16 at 10:25 am, and 1:40 pm, without a splint to her right hand. Resident #12's restorative program summary, dated 10/5/16 through 11/4/16, stated the splint had been applied on 3 days and refused on 10 days. There was nothing documented for the other 17 days. During an interview on 11/4/16 at 1:15 pm, LN #5 indicated the splint had not been applied daily as ordered by the physician. 3. Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #1's quarterly MDS assessment, dated 9/21/16, documented intact cognition, able to make needs known, and to understand others, requires total assistance with all ADL's, had impaired ROM to both upper and lower extremeties, received PROM 4 out of 7 days and assistance with splint or brace 6 out of 7 days. Resident #1's ADL/Mobility Care plan, dated as reviewed on 7/20/16, included an intervention for finger spreader splints to be placed in the evening and to be removed at the start of every day shift. The intervention stated, When off - roll up wash cloth and place in hands to keep fingers and thumbs from curling down fully and replace as they get damp. Resident #1's current Physician order [REDACTED]. a. Resident #1 was observed without a rolled up wash cloth in either hand palm on 11/1/16 at 1:35 pm, and 11/2/16 at 10:45 am. Resident #1 stated he had to ask the staff to put the rolled up wash cloth in the palms of his hands. He stated he asked the staff about once a week. b. Resident #1's TAR's for August and September 2016 contained documentation that the bilateral palm guards were not consistently applied to and/or removed from Resident #1's bilateral palms as ordered. In August, the palm guards were not applied 5 out of 31 times and not removed 5 out of 31 times. In September, the palm guards were not applied 5 out of 30 times and there was no documentation that the palm guards were removed 30 out of 30 times. On 11/2/16 at 4:10 pm, LPN #1 stated Resident #1 did not wear splints during the day, he wore them at night.

Based on observation, record review, and staff interview, it was determined the facility failed to provide medically related social services for a resident who had been sexually assaulted in the facility. This was true for 1 of 24 residents (#23) sampled for social services and resulted in harm when the resident exhibited signs of continued distress that were not addressed through on-going counseling or other services. Findings include: Resident #23 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A Social Service Progress Note, dated 5/5/16, documented Resident #23 was cognitively intact. The 14-day MDS assessment, dated 7/14/16, documented Resident #23 was able to make herself understood, understood others, and was cognitively intact. A Mood and Behavior Symptom Assessment care plan, initiated May 2016, documented the following interventions: * Monitor for signs and symptoms of depression. * Visit with resident 1:1 to allow for communication of feelings and concerns. A Social Service Progress Note, dated 5/5/16, documented Resident #23 was cognitively intact with minimal symptoms of depression. A Social Service Progress Note, dated 7/12/16, documented Resident #23 had major depression that was moderately severe. An Incident Summary, dated 7/22/16, documented that a male resident, whose care plan required him to have 1:1 supervision, touched Resident #23's face, and then slid his hand down to her chest before staff could intervene. Resident #23 denied suffering any physical injury from the incident, but stated she was emotionally upset from the assault. A Reporter Statement, dated 7/22/16 at 8:50 am, documented Resident #23 called RN #1 to her room. When RN #1 entered the room Resident #23 burst into tears and stated, I was just molested. (Resident #24) across the hall came into my room and touched me inappropriately. He patted my head then moved his hands down to my breasts. I tried to stop him and (Resident #24's 1:1 aide) tried to get him out of my room. Nurses' Notes, dated 7/22/16 at 8:50 am, documented that Resident #23 reported to staff that a male resident pushed her wheelchair to her room, ran his hands over her head, down her shoulders and over her breast. She stated this brought up bad memories from her past. Resident #23 was in bed hugging a stuffed animal as she spoke and began to cry. A psychologist note, dated 7/22/16 at 3:35 pm, documented that Resident #23 was upset because a male resident took liberties with her that morning and it brought up memories of a past sexual abuse. Nurses' Notes documented the following: * 7/22/16 - Resident #23 experienced a resident-to-resident altercation initiated by a male resident, she complained the encounter evoked symptoms of PTSD related to a past experience, staff would continue to monitor, and there were no signs or symptoms of physical injury. * 7/24/16 - Resident #23 had been talking about the assault and that facility staff did not seem concerned. * 7/25/16 at 3:30 am - Resident #23 was in bed most of the shift except to smoke, and there were no signs or symptoms of physical injury related to the altercation. * 7/26/16 at 12:45 pm - Resident #23 required excessive amounts of time from staff at that time. * Nurses' Notes, dated 7/26/16-7/28/16, did not include documentation of the sexual assault by a male resident. Social Services Progress Notes from 7/12/16 - 8/23/16 did not include documentation of the sexual assault, or how Resident #23 was coping with the incident. Resident #23's Mood and Behavior Symptom Assessment care plan, initiated May 2016, was not updated after the sexual assault. A psychologist note, dated 8/1/16, documented Resident #23 was frustrated by the facility's lack of response to the sexual assault by a male resident. On 11/1/16 at 10:30 am in a Resident Group meeting, Resident #23 stated she wanted to talk to surveyors about a sexual assault that happened to her in the facility. She asked surveyors not to come straight to her room so staff would not see surveyors meeting with her. On 11/3/16 at 8:30 am, Resident #23 stated that in early summer there was a male resident across the hall who was to have 1:1 supervision, but who pushed her wheelchair with her in it into her room, where he then touched her head, shoulders, and then grabbed her breast. She called out for help and the 1:1 aide tried to get him out of her room. She started crying and the male resident left her room. She stated that she was still upset, several months later, because it brought up memories of a previous sexual assault from years prior. She stated that she was spending more time in her room and not participating in activities she once enjoyed because of the assault. As the resident spoke with the surveyor, she stated she was worried staff would find out she was talking to the State. On 11/3/16 at 4:35 pm, the DON provided an incident report, which did not contain statements from residents involved in the sexual assault, staff witness statements, or social service notes. The facility's Social Worker and 1:1 aide for the male resident at the time of the event were no longer at the facility or available for interview.

Based on family member and staff interview, observation, and record review, it was determined the facility failed to prevent the development and worsening of pressure sores and failed to provide services to promote healing for 3 of 14 sampled residents reviewed for pressure ulcers (#3, #8 and #18). This failure resulted in harm to Resident #3 when he experienced a deep wound where bone and ligaments were exposed causing osteo[DIAGNOSES REDACTED] (a serious bone and bone marrow infection requiring medical intervention). The facility also failed to provide protein supplements to promote wound healing for Resident #8, and failed to document or evaluate a stage 2 pressure ulcer for Resident #18, a closed record review. Findings include: 1. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The record indicated that Resident #3 was readmitted to the facility on [DATE]. Resident #3's admission MDS assessment, completed on 5/16/16, stated the resident had no cognitive impairment, required total assistance with all activities of daily living due to the paralysis of all four limbs and below the neck caused by the sudden onset of [DIAGNOSES REDACTED] (a rare but serious [DIAGNOSES REDACTED] disorder in which the immune system attacks healthy nerve cells in the peripheral nervous system leading to paralysis). The MDS indicated that Resident #3 was admitted with a stage 3 (loss of full thickness of skin involving subcutaneous tissue) pressure sore on the coccyx (tailbone). Resident #3's Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer-initial identification form, dated 5/13/16, 4 days after admission, documented, One site per page, complete weekly. The weekly pressure ulcer forms showed worsening of the wound with infection from a stage 3 to a stage 4 with exposed bone and ligaments. The pressure ulcer forms documented the following: * 5/9/16 - Coccyx, stage three, 1.5 X 1.0 X 3 cm (Centimeters). * 5/13/16 - Stage three, 1.7 X 1.0 X 0.25 cm * 5/23/16 - Stage three, 3.5 X 2.5 X 2 cm, stage 3 with 80% slough, moderate odor, santyl appears effective * 6/13/16 - Stage three, 3.8 X 2.0 X 1.0 cm * 6/16/16 - Stage three, 4.25 X 2.1 X 0.75 cm * 7/12/1 6 - Stage four, 4.0 cm X 3.3 cm X 3.0 cm, undermining X 4, wound is a stage 4 with exposed bone and ligament * 7/26/16 - Stage four, 4.4 X 2.8 X 1.4 cm. Small amount of bone exposed. MRI (Magnetic resonance imaging) results with [DIAGNOSES REDACTED]. * 8/1616 - Stage four, 5.0 X 2.5 X 1.5 cm. undermining has opened and extending wound margins, MD (Medical Doctor) notified * 9/1/16 - Stage four, 4.5 X 3.5 X 1.0 cm, wound VAC dressing * 9/13/16 - Stage four, 3.7 X 2.8 X 0.7 cm, wound vac change, wound bed with healthy granular tissue, smaller in size physician's orders [REDACTED]. Change every 3 days and as needed. (Wound VAC is a therapeutic technique using a vacuum dressing to promote healing in wounds to increase blood flow to the area). On 11/2/16 at 9:00 am, during an interview with the DON, he said he was aware of the worsening of the pressure ulcer for Resident #3. The DON stated Resident #3 refused to be repositioned. The DON provided a Refusal of Care or Treatment document, dated 6/6/16. The document included, Worsening wound condition, osteo[DIAGNOSES REDACTED], infection,[MEDICAL CONDITION], and possible death. Presented to family and resident, they are not in agreement and refuse to sign. Resident and family will not sign. The DON also provided a document that he had placed at the bedside of Resident #3. The DON stated that he instructed staff to write down every time Resident #3 refused to be turned or repositioned every 2 hours. The document included Progress Notes, dated 5/24/16 through 6/14/16. The document showed a total of 8 days where Resident #3 refused to be repositioned at least once every 2 hours. A Compressed Behavior Report, dated 5/9/16 through 8/29/16, Rejection of Care, documented a total of 18 days where Resident #3 refused to be repositioned at least once every 2 hours during a period of 100 days. On 11/2/16 at 9:30 am, the DON provided a document titled, Mitigating Factors for the Development of Pressure ulcers. The document specified non-compliance with care regarding turning and repositioning, and included laboratory results of low [MEDICATION NAME] ([MEDICATION NAME] is an indicator of the bodies protein level which is essential to help the body heal wounds) indicating risk factors for skin breakdown. The document did not indicate Resident #3 had experienced significant weight loss. On 11/2/16 at 2:00 pm, during an interview with the Registered Dietitian (RD), the RD stated Resident #3 was well known to her and she had been providing nutritional recommendations for Resident #3 from the time of admission to the facility. The RD stated, He has not had significant weight loss, in fact, he has gained weight. He receives nutrition by way of a gastric tube and I added pro-stat when his wound got worse. The low [MEDICATION NAME] was likely affected by the infection in his wound. His tube feeding is providing adequate calories and protein with the added support of pro-stat AWC which is a protein supplement for advanced wound care. On 11/3/16 at 10:30 am, CNA #4 stated, I've been working with him for two months, he had never refused to let me turn him. He will say to come back later and we go back in to turn him. He lets us know if he is soiled and we clean him up. On 11/3/16 at 10: 40 am, CNA #5 stated, He sometimes refuses but if you talk to him to find out how he wants to be positioned he will let you turn him. On 11/3/16 at 4:00 pm, during an interview with a family member of Resident #3's, the family member verified that Resident #3 and the family member refused to sign the refusal of care or treatment document. The family member stated, He only refuses when he is in pain, and they usually come back after a few minutes to ask him again. His wound got worse when therapy had him sitting in a wheelchair. He was put in a wheelchair on May 19 and 21. It hurt him so much to sit on the wound. Occupational Therapy Notes (OTN), dated 5/23/16, documented, Therapy follow up with patient and wife regarding wheelchair, patient declined getting in wheel chair today due to respiratory issues and discomfort on bottom. Follow up with nursing, increase in size of wound. An OTN, dated 5/24/16, included, Discussed with spouse and patient about being up in wheelchair, reports she would like to hold off due to the sacral sore. She reports appears larger since being up in wheelchair. An OTN, dated 5/26/16, documented, Patient requiring passive range of motion and caregiver training for upper extremities and slow wound healing and pain prohibiting up in wheelchair this week. 2. Resident #8's record was reviewed on 11/1/16 at 9:00 am. Resident #8's [DIAGNOSES REDACTED]. Resident #8's Skin grid for the pressure ulcer to his coccyx documented the resident was admitted with the stage IV (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcer. The form indicated the measurements of the pressure ulcer on 10/25/16 were 1.4 cm (centimeters) in length, 0.3 cm wide, and 0.2 cm in depth. A Progress Note, dated 10/25/16, by the Nurse Practitioner, documented, Assessment/ Plan .Pressure ulcer of sacral region, stage 3 (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed) .Impression stalled .Continue sacral dressing change .Check renal panel (laboratory test for kidney function), CBC (blood test) .[MEDICATION NAME] (test for protein) .If available: trial Juven (a protein supplement) 1 pkt (packet) PO (orally) .or .BID (twice a day) x (times) 30 days. Resident #8's physician's orders [REDACTED]. During an interview on 11/1/6 at 10:30 am, the 600 Hall registered nurse (RN) Unit Manager stated the orders had not been followed up on. She indicated she did not know what happened and it was possible medical records filed the orders and did not tell nursing. She said she would take care of the orders now. During an interview on 11/1/6 at 11:18 am, the 600 Hall RN Unit Manager said the pressure ulcer to the sacrum was a healing stage IV. The physician's orders [REDACTED].[MEDICATION NAME] .Juven 1 pkt PO BID X 30 days. Resident #8's pressure ulcer was observed on 11/2/16, with the 600 Hall RN Unit Manager present. The pressure ulcer to the resident's coccyx was pink in color and measured 1.5 cm long, 1 cm wide and 0.5 cm deep. These measurements indicated the wound had gotten larger since the assessment on 10/25/16, when it measured 1.4 cm in length, 0.3 cm wide, and 0.2 cm in depth. 3. The closed clinical record for Resident #18 indicated that he was admitted to the facility on [DATE] and discharged on [DATE]. admission orders [REDACTED]. A Skin assessment, dated 6/14/16, doucmented, Stage 1 on the coccyx with measurements of 6 cm X 9 cm. Sacral area monitor for irritation every shift, apply barrier every shift. An MDS assessment, dated 6/21/16, documented Resident #18 was admitted with a stage 1 pressure ulcer (a stage one pressure ulcer has intact skin with redness of a localized area). The MDS assessment stated Resident #18 required supervision with bed mobility with the assistance of one person. Resident #18 required extensive assistance of one person with dressing, toileting and personal hygiene. A Progress note, dated 6/28/16, documented Resident #18 was alert and oriented, able to make needs known, and Resident with checks to sacrum. Skin is non-blanchable: two open areas. Barrier cream applied. Skin condition placed on 24 hour book. A Progress note, dated 6/28/16, included, Interdisciplinary Review, Resident admitted with possible stage one area to coccyx. Barrier cream was applied. Noted with areas of peeling skin on 6/28/16. Resident #18's clinical record did not include further documentation regarding the open areas on the sacrum. The record did not contain treatment orders for the open areas and no documentation regarding an evaluation of the open areas was found. On 11/4/16 at 4:00 pm, during an interview with the DON stated there were no records of Resident #18's skin condition following the documented open areas on 6/28/16.

Based on record review, review of facility incident reports and staff interviews, it was determined the facility failed to ensure nursing staff followed residents' hypoglycemic protocol and assessed and responded to episodes of low blood sugar and change in condition. This affected 1 of 6 residents (Resident #1) reviewed for diabetic care. The failure to follow the Resident #1's diabetic plan of care resulted in harm to the resident when she became severely hypoglycemic, unresponsive, and required emergency care. Findings include: The American Diabetic Association (ADA) documented in the "Standards of Medical Care in Diabetes-2012," page S27, "...Prevention of [DIAGNOSES REDACTED] is a critical component of diabetes management. ...The stress of illness...frequently aggravates glycemic control... Any condition leading to deterioration in glycemic control necessitates more frequent monitoring of blood glucose..." The ADA defined [DIAGNOSES REDACTED] as a glucose level less than 70 mg/dL (milligrams per decaliter). The ADA recommended 15-20 grams of glucose in the treatment of [REDACTED]. If the BG level showed continued [DIAGNOSES REDACTED], the treatment and BG rechecks should be repeated until the BG level was normal. The ADA further recommended that, "[MEDICATION NAME] should be prescribed for all individuals at significant risk of severe [DIAGNOSES REDACTED]..." Diabetes Spectrum, Volume 18, Number 1, 2005 stated in Table 4 titled, "Age-Specific Considerations Regarding [DIAGNOSES REDACTED]," under the heading, "Geriatric," on page 43, "Elderly individuals may have [DIAGNOSES REDACTED] unawareness (i.e., they do not experience the early symptoms of [DIAGNOSES REDACTED]). This is particularly concerning because the blood glucose level continues to drop and may reach very serious levels (< 40 mg/dl) before [DIAGNOSES REDACTED] is recognized and treated." Resident #1 was last admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 11/25/14 admission orders [REDACTED] * Check resident's BG before meals and at bedtime, notify the physician if BG was less than 50 or more than 400. The orders also documented protocol for treating low blood glucose as; * "If BS below 70 (mg/dl) and resident is able to swallow, administer 15 - 20 grams of fast acting carbohydrate (examples given)" * "If (resident) unable to swallow, give [MEDICATION NAME] 1mg SQ (sub cutaneous) or IM (intramuscular)." * "Re-check BS approximately every 15 minutes after giving carbohydrate until 90 (mg/dl) or above. Notify MD (physician) per orders." * "Follow-up with protein snack such as peanut (butter) or cheese sandwich, diabetic nutrition bar, milk." The resident's 12/2/14 MDS admission assessment coded the resident spoke clearly, had clear comprehension, was moderately cognitively disabled with evidence of acute onset of mental change, required extensive assistance of at least one person with eating, and received insulin 7 days per week. Nursing Notes, Weekly Blood Glucose/Sliding Scale Coverage Monitoring Record (WBG/SS MR) for December 2014, documented a BG of 63 on 12/6/14 at 8:00 am, and 68 on 12/7/14 at 8:00 am. The 12/6 & 12/7 MAR/Nurses Notes documented no interventions by nursing staff. For example, the resident was not provided a fast acting carbohydrate on either day, and the blood glucose was not rechecked every 15 minutes until above 90. In addition, the resident's BG was only checked once daily on 12/2, 12/4, and 12/5. A Hospital emergency room report, dated 12/7/14, documented Resident #1 was transferred by EMS to a local hospital at 4:36 pm with a chief complaint of "unresponsiveness." The report documented EMS found the resident, "... unresponsive with a BS of 21, and administered an [MEDICATION NAME] of D50." By the time the resident arrived at the ER she was alert and responsive and complaining of being hungry. The ER fed the resident supper and checked her serum glucose which was 106. Resident #1 was discharged back to the facility at 7:30 pm with the assessment of, "Hypoglycemic episode associated with diabetes and [MEDICAL CONDITION]." Nursing staff were instructed to, "Check blood sugar frequently tonight" and "Assure adequate dietary intake." Nursing records documented these orders were followed and the resident had no further episodes of [DIAGNOSES REDACTED] between 12/8/14 and 12/29/14. An Incident Investigation Reported, dated 12/8/14, documented the events that led up to the resident's 12/7/14 hypoglycemic episode: * LN #1 documented the resident's BG was taken at 7:30 am on 12/7/14. It was 69. No action was documented by LN #1. The resident's BG was not rechecked until 11:30 am and was 80. At 1:45 CNA #3 reported the resident had not eaten breakfast or lunch and was unresponsive. LN #1 immediately assessed the resident. LN #1 stated the resident woke up with calling her name and touch, and was able to move her extremities and follow commands. LN #1 stated there was, "... no diaphoresis." * CNA #3 documented on 12/7/14 at 1:30 pm the resident would not "fully wake up" at 9:00 am, 10:00 am, or 11:30 am. CNA #3 documented, "Around 1:30 pm I asked the other aide (CNA #4) to help reposition (Resident #1). We checked her and she was dry. We tried asking yes/no questions and she wouldn't reply just opened her eyes, At 1:50 pm - 1:55 pm I told (LN #1) the resident had not eaten, drank, or voided the entire shift." * CNA #4 documented on 12/7/14, "... around 1:15 pm, CNA #3 came to me," and said that she (CNA #3) went into (Resident #1's) room to check on her... and she was unresponsive and she was sweaty, but not wet with urine, at that time we changed her bedding. She (CNA #3) reported to the nurse that (Resident #1) did not eat and did not void all shift." * The evening nurse (LN #2) on 12/7/14 documented, "(Received) information in report that resident was lethargic (and) having unusual behaviors when awake. I was able to get to her and assess her around 4:00 pm - she was alert but totally non-responsive, eyes were fixed, open, and dilated... she was thrashing in bed. I notified the MD and received orders to send her to (local hospital)... " Note: Based on staffing records, the facility nurses work 8 hour shifts. The evening shift change is at 2:00 pm. This indicated the resident was not observed until 2 hours after shift change when the LN received report that Resident #1 was lethargic, exhibiting unusual behaviors, and had not had any oral intake or urinary output. A Resident Concern Report, initiated by Resident #1's family member on 12/8/14 documented,"Resident was found shaking and out of it by son at approximately 4:07 pm, dead eyes, shaking, (and) can't get any assistance'... blood sugars were 21. .. no one helped her to eat and she did not eat breakfast or lunch... " On 12/29/14 at 2:05 PM, LN #1 was asked if she provided Resident #1 with a fast acting carbohydrate after the resident's 12/6/14 am BG of 63 or her 12/7/14 am BG of 69 and if she rechecked the resident's blood sugar before the noon meal. LN #1 answered, "No," to both questions. When asked if she had received training on the facility's and resident's diabetic protocol for [DIAGNOSES REDACTED], LN #1 said "No." LN #1's stated her hire date was November 2014 and she was not aware of the protocol until after the incident on 12/7/14. LN #1 stated she had since been in-serviced on the protocol and had a copy of it with the steps to follow. LN #1 stated during all of her interactions with the resident on 12/7/14 day shift, the resident was responsive, non-diaphoretic and did not have any concerns. When asked what she reported to the oncoming shift on 12/7/14, LN #1 stated she told LN #2 that the resident had not eaten all day or voided. CNA's #3 & 4 were interviewed on 12/7/14 between 12:10 pm and 12:15 pm. Both substantially repeated what they had written in the 12/8/14 investigative report. CNA #1 stated she did not tell the LN about the poor oral intake or absence of voiding until the end of the shift. LN #2 was no longer working for the facility and was unavailable for interview. The ADON was interviewed at various times throughout the day on 12/29/14, but stated she was not the DON when the 12/7/14 BG issue occurred. A 12/12/14 IDT review report of the 12/7/14 incident documented, "During the investigation it was discovered that the resident had refused both breakfast and lunch and LN had not been notified. FSBS (fasting blood sugar) at noon was 80, which is (with)in parameters for resident. After MD review of blood sugars bedtime [MEDICATION NAME] decreased as resident runs low in the morning. Pharmacy medication review request faxed and returned (,) MD notified of recommendation. Staff educated in regards to resident not eating, notification to the LN, also care plan updated and staff educated that resident (#1) is to eat meals in restorative dining." The 12/12/14 IDT report identified CNA #3's failure to notify the day shift LN in a timely manner of her concerns with the resident, and identified the resident had a history of [REDACTED]. 1. LN #1's failure to follow diabetic protocol for [DIAGNOSES REDACTED] on the mornings of 12/6 and 12/7 2. LN #2's failure to assess Resident #1 for 2 hours after she had been notified by LN #1 of the potential change in condition. 3. The report addressed education of staff regarding reporting low oral intake to the LN but did not address educating CNA or LN staff on recognizing the signs and symptoms of [DIAGNOSES REDACTED] in the elderly or how and when to report them. The Administrator and ADON were notified of the identified harm to Resident #1 on 12/29/14 at 3:15 pm.

Based on observation, staff interview, and record review, it was determined the facility failed to accurately identify and heal skin ulcers. This was true for 1 of 4 residents (#8) sampled for pressure ulcers and resulted in harm to Resident #8 whose Stage IV pressure ulcer remained unhealed after 10 months of residency at the facility. The facility changed its initial [DIAGNOSES REDACTED]. Additionally, the facility failed to seek cultures of the wound as it discharged odiferous drainage, or prevent the resident from experiencing "severe" weight loss when nutritional stores were essential for wound healing. Findings include: Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. NOTE: Resident #8 was admitted to the facility from a nearby hospital following a fall at home. A Discharge Summary from that hospital, dated 5/24/11, did not include any documentation related to skin impairment to the resident's sacrum or coccyx. Resident #8's admission MDS assessment, dated 5/31/11, documented the following: * No pressure ulcers present at admission to facility * Severely impaired cognitive skills for daily decision making * No behaviors * Extensive assistance of at least two staff members required for bed mobility, transfers, personal hygiene, and toileting * Height of five-feet, two inches; weight not documented The resident's most recent quarterly MDS assessment, dated 2/22/12, documented the following: * Stage IV pressure ulcer present upon admission to the facility * Severely impaired cognitive skills for daily decision making * No behaviors * Total dependence on at least two staff members required for bed mobility, transfers, personal hygiene, bathing, and toileting * Height of five-feet, two inches; weight of 127-pounds Resident #8's Pressure Ulcer CAA, dated 6/6/11, documented the following: * No existing pressure ulcers * Resident required staff assistance to "relieve pressure over any one site" * Risk factors included incontinence, on-going anti-anxiety medication administration, diabetes mellitus, [MEDICAL CONDITION]/[MEDICAL CONDITION], depression, pain, newly admitted to the facility, and functional limitation in range-of-motion. * "The resident is at risk for pressure ulcers due to need for staff assistance with bed mobility. She is on a turning and repositioning program. There are pressure reducing devices in use on the bed and in the wheelchair. Skin integrity is checked regularly." An Admission Skin Assessment, dated 5/24/11, documented a "bruise" to the resident's lower back and a "bruise" to the resident's coccyx. Both bruises were documented on a diagram of a human body and were accompanied by drawings in the applicable anatomical locations. Braden Risk Assessment Scales documented that the resident was at "high risk" for pressure ulcers on assessments dated 6/5/11, 6/9/11, and 6/16/11, and "moderate risk" for pressure ulcers on the assessments dated 6/23/11, 8/25/11, 11/15/11, and 2/22/12. Recapitulated physician's orders [REDACTED]. * "Air bed with bolsters and 1/2 side rails d/t (due to) immobility r/t (related to) [MEDICAL CONDITION] with spinal injury." Start date: 6/8/11. * "Vitamin C 500mg (milligrams) ... (for) wound healing." Start date: 6/27/11. * "Jay2 wheelchair cushion with gel spiral insert or similar to offload sacrum." Start date: 7/11/11. * "[MEDICATION NAME] Sulf(ate) 100mg (per) 5ml soln (5 milliliters solution). Give 0.25 - 0.5ml (5-10mg) orally 30 minutes prior to dressing change." Start date: 11/1/11. * "Sodium Chloride 0.9% (Normal Saline - NS) irrig(ation). Cleanse/soak affected sacrum area daily." Start date: 1/23/12. * "Sacrum: Cleanse with 1/4 strength allsept/NS, soak for 3-5 minutes. [MEDICATION NAME] (with) [MEDICATION NAME] to fill wound bed, cover (with) border gauze and change daily and as needed for soiling." Start date: 1/23/12. Resident #8's Skin Integrity Assessment: Prevention and Treatment Plan of Care with an initial assessment date of 6/2/11 and in effect at the time of survey documented the following: * "Assessment: (High Risk) - Increase frequency of turning; pressure reduction support surface; maximal remobilization; protect heels; manage moisture, nutrition, friction and shear." * "Goal: Will remain free of open areas; will be cooperative with position changes; will verbalize understanding re(garding) refusal of care outcome." * "Interventions: Complete Braden Scale upon admission and weekly times 4 weks (weeks), quarterly, and with change of condition; use commercial moisture barrier; use absorbent pads or diapers that wick (and) hold moisture; address cause if possible; increase protein intake; increase calorie intake to spare proteins, supplement with multi-vitamin (should have vitamin A, C, (and) E); act quickly to alleviate deficits; consult dietitian PRN (as needed); protect elbows and heels if being exposed to friction; no massage to reddened bony prominences; no do-nut type devices; maintain good hydration; lift (rather than slide resident during transfers and/or bed mobility); monitor weight as applicable; implement an individualized turning schedule if applicable (handwritten note that read 'side to side only (every) 1-2 (hours)); position body with pillows and/or other support devices; avoid positioning on trochanter; keep linen dry and wrinkle free; instruct and encourage to reposition self at 15-20 minute intervals as able; monitor wound weekly and PRN; provide treatment per MD order; and update MD within 2 weeks if no evidence of healing." The Skin Integrity Care Plan also included several handwritten entries that documented the following assessments and interventions: * Assessment: A line was hand-drawn through "admitted - low back bruise vs. DTI (versus deep tissue injury) and dated 7/25/11. Immediately under the redacted entry was another handwritten entry that read, "Kennedy's ulcer admitted - 7/25/11." * Intervention: "Specialty mattress (a line was hand-drawn through the intervention, dated 1/5/12, and written by hand rather than by type was 'low air loss')." * Intervention: "(Name of Nurse Practitioner and Certified Wound Nurse - ARNP) referral 6/21/11." Skin Grid Pressure/[MEDICAL CONDITION] Ulcer/Other forms documented the following information for the wound to the resident's sacrococcygeal area: * 5/24/11 - Hematoma/blister/DTI measuring 3cm (centimeters) by 3cm with no drainage or color. No depth recorded. * 6/7/11 - No staging of wound provided. 1cm by 1cm in size. No depth recorded. Pink in appearance. Serosanguinous drainage. No odor. No tunneling recorded. "Area of sloughed tissue to hematoma/blister to low back. 3X3 (centimeter) bruise noted to peri wound. No c/o (complaints of) pain." * 6/14/11 - No staging of wound provided. 1cm by 1cm in size. No depth recorded. Necrotic in appearance. Serosanguinous drainage. No odor. No tunneling recorded. "100% slough to wound bed, bruise to periwound resolved (and) WNL (within normal limits), defined edges, santyl added to treatment, no c/o pain/discomfort." * 6/20/11 - "DTI vs. Kennedy" staging of wound. 1.5cm by 1cm in size. No depth recorded. Serosanguinous drainage. Necrotic in appearance. No odor. No tunneling recorded. "Copious amounts of drainage, 95% slough; 5% necrotic. Defined edges, peri wound dusky grey/purple. (ARNP name) referral in place." * 6/27/11 - "Pressure vs. Kennedy" staging of wound. 4.3cm by 2.5cm by 0.2cm in size. Serosanguinous drainage. Necrotic in appearance. No odor. No tunneling recorded. "(ARNP name) in new classification of wound, new orders received. 5cm (by) 3cm area of induration to peri wound, denies pain, defined edges." * 7/5/11 - "Pressure vs. Kennedy" staging of wound. 3.2 by 2.9 by 0.9cm in size. Serosanguinous drainage. Necrotic in appearance. Foul odor. No tunneling recorded. "(Increased) depth (secondary) to debridement. No c/o pain, peri wound (with) 2cm of induration at 9 o'clock, defined edges. MD (and) family aware. 10% slough, 90% necrotic." * 7/12/11 - "Pressure vs. Kennedy" staging of wound. 6.7 by 4.4 by 0.2cm in size. Serosanguinous drainage. Necrotic in appearance. Foul odor. No tunneling recorded. "100% necrotic, (increased) in size (secondary) to induration opening. (ARNP name) into (sic) see resident, peri wound WNL, defined edges. No c/o pain/discomfort." * 7/19/11 - "U" staging of wound (Unstageable). "Original wound (measured) 7 by 7 by 0.5cm. Opening at end of tunnel (measured) 3 by 5cm, communicating (tunnel) to labia (measured) 3 by 2cm." Purulent drainage. Necrotic in appearance. Foul odor. "Original (tunneling/undermining depth) 8cm." "(ARNP name) in reclassified wound as Kennedy's ulcer; 8cm tunnel connects 2 wounds, copious drainage, foul odor. 100% necrotic (with) foul odor." NOTE: The Skin Grid documentation forms provided to surveyors (the documents were not in the resident's medical chart) documented wound size, appearance, odor, and tunneling with detailed information approximately every week through 2/7/12. The last Skin Grid form given to surveyors during the facility's annual re-certification and licensure survey, 3/11/12 through 3/15/12, documented the following information: * 2/7/12 - "Kennedy's" staging of wound. 5.6 by 6 by 2cm in size. Serousanguinous drainage. Pink in appearance. No odor. Bone visible within the wound. No tunneling recorded. "98% granulation, 2% slough, limited healing noted, moderate amount of serosang(uinous) drainage noted. Peri wound WNL. No c/o pain/discomfort." The facility provided surveyors with Routine Visit Records - Wound Care, each signed and dated by the ARNP from 6/27/11 through 3/5/12. The wound in those reports was variously referred to as "Stage IV, Kennedy's, Kennedy's-Stage IV, Pressure vs. Kennedy's," etc. Those reports documented, in part: * 6/27/11 - "... seen by ... request for DTI observed on admit to (facility) 5/24/11. RCM (Resident Care Manager) reports area appeared as purplish, soft area, progress to open area distally (with) necrotic base proximally. Sacral DTI - unstageable ulcer (Kennedy's vs. pressure) (downward pointing arrow) nutr(ition)." * 7/21/11 - "... seen for assessment of sacral ulcer by RCM request: new onset perineal ulcers (with) foul odor, increased drng (drainage), tunneling (and) perineal induration. (Discussed with family member that) healing is doubtful, but not impossible - extensive wound (with) SQ (subcutaneous) tunnels near rectum (need [MEDICAL CONDITION]), tunneling to buttocks/perineum. High risk for infection (secondary) to repeated contamination. (Family member) does not want surg(ery) intervention at this time. Consider Hospice. Cont(inue) comfort meas's (measures). Kennedy's Ulcer (not pressure related) - extensive SQ tunneling, non-healing." * 7/25/11 - "Cont(inue) same tx (treatment). Healing unlikely - exposed bone, extensive ulcers." * 8/2/11 - "All wounds communicate SQ. Some healing possible, closure doubtful." * 10/31/11 - "(Resident #8) seen for f/u (follow-up) of sacral ulcers. Aide (CNA) (and) LN reports good PO (oral) intake (with) freq(uent) supps (dietary supplements) ... (Resident #8) alert, states she 'isn't feeling very good' today, does not elaborate. (The resident) c/o (complains of) intermittent LBP (lower back pain) ((secondary) to ulcer). Sacral/perineal Kennedy's (Stg IV) - healing. (Downward pointing arrow) nutr - cont's (continues) supp's." * 1/10/12 - "(Resident #8) seen for f/u of sacral ulcer. (She is) alert, irritable, shouting at aides/LN for cares/repositioning. Sacral Kennedy's/Stg IV - cont'd (continued) healing. (Downward pointing arrow) nutr - stable (with) supp's." * 1/23/12 - "(Resident #8 is) alert, resting in bed, less agitation/combativeness today. Expresses irritation (with) cares, but (no) attempts to strike/bite at pres(ent). Sacral Kennedy's/Stg IV - healing prev'ly (previously) now stalled. New evidence of prox(imal) DTI. (Downward pointing arrow) nutr - con't supp's." * 3/5/12 - "Sacrum Stg IV (measured) 5.2 by 3.2 by 0.5cm (with) 100% granulation present, no bone exposed, moderate serosanguinous drainage, periwound intact, no odor." NOTE: The Routine Visit Records made repeated references to Resident #8's nutritional status. Please refer to F325 as it relates to Resident #8's severe weight loss during the same time period covered by the Routine Visit Records. Resident #8's Nurse's Notes from 5/28/11 through 3/13/12 were reviewed and documented the following: * 5/28/11 - "F/C (Foley catheter) patent, check and turn (every two hours) and PRN ..." * 6/6/11 - "Area noted on admit bruise/blister/DTI to low back (with) thin tissue cover, now open, treatment in place, resident was placed on Stat II air mattress (secondary) to fragile tissue, RD (Registered Dietitian) referral in place, MD (and) family resident (with) quadraparesis (and) on a turning schedule will continue to monitor until resolved." NOTE: The 6/6/11 entry, 13 days after the resident was admitted to the facility, was the first documentation in the resident's Nurse's Notes of a skin issue involving the resident's back. * 6/10/11 - "... Hospice for admit per (physician)." * 6/20/11 - "IDT (Interdisciplinary Team) review of wound to low back: Resident admitted [DATE] (with) multiple skin issues noted on admit. 3X3cm bruise to low back noted, possible deep tissue injury suspected, area (with) 90% slough, 10% necrotic to wound bed. Resident currently on a side to side positioning schedule, ... hospice referral received 6/10/11. New wound orders received 6/14/11. Periwound a dusky purple, bruising has resolved. Open area measuring 1X1.5cm (with) defined edges, resident denies pain. Spoke (with family member secondary to) wound not progressing (and) requesting for wound consult (with ARNP's name), (family member) was amenable." NOTE: A FAX from an area Hospice agency to the facility, dated 6/21/11, documented, "(Resident #8) doesn't qualify for hospice services while getting (occupational) therapies (and) treatment (at) your facility. Please consider hospice services with us when (Resident #8) is discharged from your facility or when the 100 day stay period (for Medicare insurance coverage of therapies) is over. (Facility staff member) said 100 days ends 8/31/11." * 7/26/11 - "(ARNP) in to see resident's wound yesterday afternoon. Prognosis is very poor (without) surgical interventions which resident may (not) be a candidate for ... WCT (will continue) (with) comfort as goal at this time." * 7/29/11 - "Premedicated with [MEDICATION NAME] 10/325(mg) prior to dressing (change). Wound foul smelling, difficult to keep stool out of d/t (due to) location ... Resident did moan during dressing change, when asked if it was painful she said 'yes.' - Late entry (for) 7/28/11 - Resident's (family member) with return call. Discussed worsening of wound (and) poor prognosis assoc(iated) (with) this. Tx options discussed including surgical intervention (with) placement of VAC (wound-vac). (Family member) does (not) want this tx. Tx will continue to be purely palliative at this time (with) pre-medication prior to (dressing changes)." * 8/2/11 - "Res(ident) given PRN [MEDICATION NAME] 10(mg) one hour prior to drsg change to coccyx." * 8/4/11 - "New order received to start Roxinol 30 min(utes) (before) drsg (changes) for pain relief for drsg (changes)." * 8/25/11 - "IDT review of abrasion noted 8/20/11 - Resident (with) Dx (diagnosis) of Kennedy's terminal ulcer, which requires dressing (changes) 2-3 times daily ..." NOTE: The 8/25/11 entry was the first documentation in the Nurse's Notes of the resident having a [DIAGNOSES REDACTED]." On 3/14/12, at 9:20 a.m., the surveyor asked the unit manager for Resident #8's unit (UM #6) to see a dressing change on the resident. UM #6 stated that dressing changes to the resident's sacral area wound were performed between 4:00 a.m. and 5:00 a.m. and when the dressing became soiled by incontinent stool. On 3/14/12, at 12:15 p.m., surveyors interviewed the ARNP. When asked whether she was aware that "Kennedy's Terminal Ulcer" was a theory rather than a bonified medical diagnosis, the ARNP stated that her training and expertise convinced her of the diagnosis's validity. NOTE: According to the National Pressure Ulcer Advisory Panel, in an article entitled, "Ostomy Wound Management," February 2011, and available at www.o-wm.com, documented, "Due to their physical condition, illness, psychological issues, and at times a social-cultural aspects, terminally ill individuals are at increased risk of pressure ulcer development. Some dying individual develop what have been called Kennedy terminal ulcers, described as pressure ulcers that present as pear-shaped purple areas of skin, often on the sacrum, seen 2 to 3 days before death. These ulcers have been described as rapidly appearing sacrococcygeal ulcers in the shape of a butterfly or pear with irregular borders. The Kennedy Terminal Ulcer has had little formal study. Although called a terminal ulcer, patients with these wounds sometimes die in a matter of hours and sometimes live for more than 6 weeks. The varied length of life makes the [DIAGNOSES REDACTED]. There was no vote taken on Kennedy Terminal Ulcers." When asked how she determined the wound was a "Kennedy's terminal ulcer," the ARNP stated, "I didn't feel it was a pressure ulcer because of the multiple eschar (areas) below the site." The ARNP also stated that the wound's patterning and color suggested to her that the wound was a Kennedy's terminal ulcer. NOTE: According to a 3-page print out the facility provided to surveyors from http://www.kennedyterminualulcer.com, a "Kennedy Terminal Ulcer is a pressure ulcer some people develop as they are dying. It usually presents on the sacrum. It can be shaped like a pear, butterfly or horseshoe. It can have the colors of red, yellow, black or purple. The borders of the ulcer are usually irregular. It usually starts out as a blister or a Stage II and can rapidly progresses (sic) to a Stage III or a Stage IV. In the beginning it can look much like an abrasion as if someone took the patient and drug his or her bottom along a black top driveway." When asked to identify which of the resident's admission [DIAGNOSES REDACTED]. When asked whether the wound was ever cultured for infection after its "foul odor" was detected, the ARNP stated that Resident #8 was "probably going to die so no diagnostics (were performed) ... (the ARNP) took a wait and see (approach to potential infection of the wound)." On 3/15/12, at 9:35 a.m., surveyors were taken into the resident's dimly lit room to observe a dressing change to the resident's sacral wound. When asked to measure the wound, LN #8 used a sterilized q-tip and measurement scale to measure the wound and then reported to surveyors that the wound measured 5cm by 5cm by 2.9cm. When asked to measure tunneling observed in the wound bed at the 9-o'clock position, LN #8 measured the depth of the tunnel and reported it to measure one centimeter in length. At one point during the dressing change, Resident #8 stated, "You're hurting me." At the time of her discharge to the facility from a nearby hospital, Resident #8 was not documented as having any skin impairment to the sacral area. Upon admission to the facility, the resident's admission MDS assessment did not document any skin impairment, however an initial skin assessment conducted the same day the resident arrived at the facility documented a "bruise" on the resident's sacrum. The resident's Pressure Ulcer CAA also did not include any reference or documentation of a sacral bruise or skin comporomise. Soon after, the "bruise" documented on the resident's initial skin assessment was classified by the facility in turns as a blister, hematoma, possible deep tissue injury, Stage IV pressure ulcer and, finally, a Kennedy's Terminal Ulcer. The so-called Kennedy's Terminal Ulcer, however, has not attained status as a bonified medical diagnosis, but rather remains only a theory. Resident #8's overall condition as well as the condition of the wound, however, did not meet the criteria of a "Kennedy's Terminal Ulcer" as outlined by the advocacy group according to material provided by the facility. treatment of [REDACTED]. When the wound began emitting odiferous drainage, the facility failed to advocate for diagnostic evaluation, deferring instead to the "diagnosis" that the resident's condition was "terminal." In addition, Resident #8 experienced significant and severe weight loss while at the facility, which adversely affected the resident's wound-healing ability. The facility failed to adequately diagnose and treat a Stage IV deep tissue injury/pressure ulcer that has remained unhealed and open for approximately 10 months.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents with limited range of motion (ROM) received rehabilitative services as ordered by a physician and care-planned. This was true for 1 of 5 residents (#8) sampled for ROM and resulted in harm when Resident #8 developed severe contractures to her left hand and wrist. Findings include: NOTE: A hospital History and Physical, dated 5/16/11 after the resident was admitted there following a fall at home, documented, "(Resident #8) notes marked pain and discomfort with elevation of the left arm. She has marked pain in the left wrist as well as the left elbow. She has great difficulty with mobility, and the left arm is held at an unusual angle with hyperextension of the left elbow as well as the wrist ... there is pain with palpation involving the left wrist." Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #8's ADL CAA, dated 6/6/11, documented, "The resident communicates that she requires more assistance for ADLs than is normal for her. She is working with therapy to regain enough strength and independence to return to her home with a caregiver. Will proceed to care plan to communicate therapy program and plan to staff, and address interventions." A Restorative Resident Summary Report, undated, documented that Resident #8 began a "Passive ROM Program" on 7/14/11. The Report also documented the following: * "Goal: Resident will remain free of contractures/decreased ROM to bilat(eratl) upper and lower extremities with participation in therapy program." * "Interventions: Gentle PROM to bilat UE/LE 15 min/day up to 6x/week (Gentle Passive Range of Motion to bilateral upper extremities/lower extremities (for) 15 minutes daily six times a week)." * "Program Notes: (8/8/11) - Resident noted to be participating well in program. Tolerating program without problems. Goal remains approp(riate) at this time. (9/28/11) - Resident toleration PROM program well. No declnies (sic) noted at this time. Splint application program recently added to help prevention of contracture. (11/21/11) - Resident noted to be actively participating in ROM program. Poor participation noted in splint application program. Staff inserviced on importance of splint application to prevent formation of new contracture. No declines noted at this time. (12/14/11) - Resident continues to p-articipate (sic) in the program and tolerates it well. One decline noted during the thirty day assessment window. No declines in ROM noted. (1/12/12) - Resident noted to have poor participation this month with 6 refusal days and 6 tolerating poorly days. 13 days of participation noted and resident tolerated well. No declines in ROM noted. Spoke with RNAs (restorative nursing aides) regarding notification of LN of frequent refusals. (2/27/12) - Resident noted to have poor participation this month with 6 refusal days and 6 tolerating poorly days. 13 days of participation noted and resident tolerated well. No declines in ROM noted. Spoke with RNAs regarding notification of LN of frequent refusals. (2/27/12) - Resident with noted improvement in refusals during the 30 day assessment period. 9 days of participation with only 3 refusals noted." An Occupational Therapy (OT) Plan of Care, dated 8/30/11, documented, "(Resident #8) was admitted (to the facility) with a history [MEDICAL CONDITION] resulting residual deficits impacting the patient's ability to perform hand hygiene. Therapy is necessary for improving LUE PROM (left upper extremity passive range of motion) for bathing, dressing and hand hygiene. Without therapy patient is at risk for (left) hand flexion contractures." The Plan of Care documented the resident "tolerates left palmer guard for 30 minutes" and set a goal that the resident would "tolerate left finger extension for 45 minutes, with application of palmer guard and wrist cock up splint in order to enhance maximum ROM and joint alignment thus preventing deformity and pain." The plan documented that therapeutic services were to occur "5 times a week for 4 weeks." Physician's Telephone Orders, dated 9/1/11, documented, "D/C (Discontinue) skilled OT on 8/31/11 (secondary) to (insurance) payor (sic) change. Skilled OT to eval(uate) and treat (with therapeutic exercise) ... splint, massage, and manual (treatment) for (decreased) ROM of (left) UE to (decrease) risk of contracture for hand hygiene, bathing, and dressing." A 9/2/11 Physician's Telephone Order clarified OT services for five times per week for four weeks. An OT Therapist Progress Report and Discharge Summary, dated 9/1/11 at 1:11 p.m., documented the resident was "cooperative with POC (Plan of Care)." An OT Plan of Care, dated 9/1/11 at 1:25 p.m., documented, "(Resident #8) tolerates left palmer aurd (sic) with wrist cock up splint for 45 minutes" under the heading, "Current Level of Function." Under the heading, "Goal," the POC documented, "The patient will achieve all digit finger extension for 1 hour with application of forearm based all digit resting hand splint in order to improve hand hygiene." A Restorative Resident Summary Report, undated, documented the resident began a Restorative Therapy (RT) "splint or brace program" on 9/16/11 and included the following "Program Notes": * 12/14/11 - "Goals remain appropriate for resident. Participation noted to be poor. Spoke with resident and RAs (restorative aides) about importance of scheduled frequency of program. Will ... review/make changes quarterly/PRN (as needed) as appropriate." * 1/12/12 - "Resident participation continues to be poor with 11 refusals noted at this time." * 2/27/12 - "Resident with continued refusals at this time. Spoke with resident care manager (RCM) regarding resident poor participation and refusals. RCM feels that program remains beneficial at this time. Goals remain appropriate. Will continue to assess monthly for participation and changes." The resident's most recent quarterly MDS assessment, dated 2/22/12, documented the following: * Severely impaired cognitive skills for daily decision making * No behaviors * Bilateral decrease in ROM for both upper- and lower extremities * Total dependence on at least two staff members required for bed mobility, transfers, personal hygiene, bathing, and toileting Recapitulated physician orders, dated 2/29/12, documented the following orders, each with a start date of 5/24/11: * "Physical Therapy to evaluate and treat as indicated." * "Occupational Therapy to evaluate and treat as indicated." * "Restorative aids/nursing rehab programs." Resident #8's ADL/Mobility Plan of Care in effect at the time of the facility's annual re-certification and licensure survey, 3/11/12 through 3/15/12, documented "Problems" of "arthritis, [MEDICAL CONDITION], (and) [MEDICAL CONDITION] disc disease." A box labeled "contractures" under the heading "Problem" was blank and the Care Plan did not include any documented "Goals" or "Interventions" associated with contractures. A Restorative Detail Report documented that Resident #8 participated in the "Splint or Brace Program" for a total of 40 minutes from 10/25/11 through 3/13/12. The Report documented "Resident Refused" on 40 occasions, and "Not Scheduled On This Shift" for 226 shifts. Resident #8 was observed on 3/12/12 at 7:40 a.m., 9:10 a.m., and 12:57 p.m.; 3/13/12 at 9:00 a.m. and 1:15 p.m.; 3/14/12 at 9:20 a.m., 9:50 a.m., and 3/15/12 at 9:35 a.m. The resident, whose left hand and wrist were severely contracted in a decorticate position with the thumb protruding from between the second and third fingers, was not wearing a brace or splint to her left hand/wrist during any of those observations. On 3/13/12, at 1:15 p.m., Resident #8 was interviewed. When asked whether she normally wore a splint or brace to the contracted left hand and wrist, and whether the severe contracture of the wrist and hand was painful, the resident stated, "I'm fine." On 3/14/12, at 10:00 a.m., Occupational Therapist #5 (OT #5) was interviewed. When asked about Resident #8's need for therapy for the left wrist and hand, OT #5 stated the resident was wearing a splint or brace to the hand for "30 minutes" per session prior to her discharge from OT and referral to the facility's RT program. When asked to explain how important it was for the resident to wear a splint or brace to the left hand and wrist, OT #5 stated, "We knew (that) without therapy and splint she ran the risk of contractures, yes." On 3/14/12, at 2:30 p.m., the facility's Administrator was interviewed. When asked to explain why RT did not provide the resident with therapy and equipment to prevent contractures as physician-ordered and care planned, the Administrator stated, "We'll take ownership on that one; we didn't do well there." No further information was provided by the facility.

Based on record review and staff interview, it was determined the facility failed to sufficiently intervene when a resident experienced severe weight loss. This was true for 1 of 4 residents (#8) sampled for weight loss. Resident #8 was harmed when she lost 9.7-percent of her total body mass in a one month period. This severe weight loss adversely affected the healing of an open wound on the resident's sacrum (Please see F314). Findings include: Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. NOTE: Resident #8 was admitted to the facility from a nearby hospital following a fall at home. A Daily Progress Note from that hospital, dated 5/16/11, documented the resident was to be "gently rehydrate(d)" and "nutritional intake increase(d)" for "[MEDICAL CONDITION]." [MEDICAL CONDITION], however, was not among the resident's admission diagnoses. The resident's 14-day admission MDS assessment, dated 6/3/11, documented the following: * Height of 5-feet, 2-inches; weight of 174-pounds * Extensive assistance of one staff member required for eating The resident's most recent quarterly MDS assessment, dated 2/22/12, documented the following: * Severely impaired cognitive skills for daily decision making * No behaviors * Anti-anxiety and hypnotic medication therapies * Stage IV pressure ulcer present upon admission * "Occasional" pain rated at "5" on the 1-10 scale * Limited assistance of one staff member required for eating * Mechanically altered foods * Height of five-feet, two inches; weight of 127-pounds Resident #8's ADL Functional Status CAA, dated 6/6/11, documented, "Nutritional Problems;" under the heading, "Eating," the CAA documented, "Physical limitations: weakness, limited ROM (range of motion), poor coordination, visual impairment, pain, etc.;" and "TREATMENT to achieve highest practical self-sufficiency." Recapitulated physician's orders [REDACTED]. * "Diet: Dysphagia 1, NTL (nectar thick liquids), liberalized, NTL with enhanced foods." Start date: 2/6/12. * "MedPass 2.0: Give 120 ml (milliliters) by mouth four times daily (weight maintenance)." Start date: 1/11/12. NOTE: Resident #8's recapitulated physician's orders [REDACTED]. * [MEDICATION NAME], 10mg (milligrams), three times daily - abnormal taste, nausea * [MEDICATION NAME], 20mg daily - nausea, decreased appetite * Ambien, 5mg daily - abdominal pain, nausea The resident's Nutritional Risks Care Plan, dated 2/6/12, documented the following: * "Assessment/Problem: Diabetes, consumes (less than) 75% (of meals), mech(anically) alt(ered) diet, weight loss, end-stage disease process." NOTE: A handwritten entry next to "end-stage disease process" documented "Kennedy ulcer." A "Kennedy's" ulcer, however, is a theoretical sign/symptom, rather than cause, of impending death. None of the [DIAGNOSES REDACTED]. Please refer to Federal Citation F314. * "Goal: Resident will consume at lease 65-75% of meals; open areas will show s/s (signs and/or symptoms) of healing - sacral area." * "Interventions: Provide diet as ordered; assist with meals as needed PRN (as needed); monitor weights per policy; vitamin and/or mineral ordered; supplements as ordered MP (Med Pass) 2.0; monitor intake of meals and offer alternate PRN; Provide fortified foods PRN; monitor tolerance to diet texture at meals." A Nutrition Risk Data Collection and Assessment form, dated 6/1/11, documented the following: * Usual body weight of 160-pounds * Ideal body weight of "99 (110) 121" (pounds) * "Appears well nourished (and) [MEDICAL CONDITION]" * Nutritional intake averages by meal = 71-percent breakfast, 42-percent lunch, and 39-percent dinner * Antibiotic therapy and [MEDICATION NAME] * "(No) pressure (ulcers), (positive for) bruises" * "Nutritional Assessment: Recent abx (antibiotic) for UTI (urinary tract infection) - can negatively affect appetite. PO (Oral) intake has been variable thus far. Tolerates altered textures. Admit (with) [MEDICAL CONDITION] in hands - (not) on diuretic. Appears (within ideal body weight) range - awaiting recent weight (stated) UBW (usual body weight) is (above) IBW (ideal body weight) range. Will cont(inue) current POC (Plan of Care)/monitoring." Nutrition Progress Notes - dated 8/22/11, 11/17/11, and 2/6/12 - documented the following: * 8/22/11 - "Current weight of 138.9-pounds - Weight 30 days ago: 142.4-pounds - Weight 60 days ago (6/13/11): 159.8-pounds - Meals (consumption percentages): 71/68/71 - Supplement/Snack (consumption percentage): 25-percent - Location meals served: MDR (main dining room) - Pertinent lab data: (6/2) alb(umin) 3.0" NOTE: Normal [MEDICATION NAME] values = 3.3-4.8. - "Skin/Wound: abrasion (left) buttock - Goals/Strategies/Interventions: Adequate PO" * 11/7/11 - "Current weight of 132-pounds - Weight 30 days ago: 131-pounds - Weight 60 days ago (8/16): 138.9-pounds - Meals (consumption percentages): (approximately) 77-percent - Supplement/Snack (consumption percentage): blank - Location meals served: MDR - Pertinent lab data: (No) new (labs) - Skin/Wound: sacrum perineum - Goals/Strategies/Interventions: Weight stability healing" * 2/6/12 - "Current weight (2/1) of 128.8-pounds - Weight 30 days ago(1/3): 121.6 - Weight 60 days ago (11/1): 132-pounds - Meals (consumption percentages): (approximately) 62-percent - Supplement/Snack (consumption percentage): blank - Location meals served: MDR -Pertinent lab data: (No) new (labs) - Skin/Wound: coccyx conts (continues) Stg (Stage) 4 - Goals/Strategies/Interventions: Healing; weight maint(enance)" A review of Resident #8's Weights Detail Report revealed the following: * (Six Month Weight Analysis): Weight on 9/14/11 of 136.6-pounds. Weight on 3/6/12 of 126.4-pounds. Loss of 10.2-pounds, or 7.4-percent of total body mass. * (Three Month Weight Analysis): Weight on 10/5/11 of 131.0-pounds. Weight on 1/3/12 of 121.6-pounds. Loss of 9.4-pounds, or 7.1-percent of total body mass. * (One Month Weight Analysis): Weight on 12/6/11 of 134.8-pounds. Weight on 1/3/12 of 121.6-pounds. Loss of 12.2-pounds, or 9.7-percent of total body mass. NOTE: Federal guidance at 483.25(i)(2) specifies that a weight loss of 5-percent in one month is "significant" and that weight loss greater than 5-percent in one month is "severe;" weight loss in excess of 7.5-percent in three months is "severe;" and weight loss in excess of 10-percent in six months is "severe." According to Understanding Normal and Clinical Nutrition, 6th ed., by Whitney, Cataldo, and Rolfes, "Rapid weight loss may cause serious health problems. Rapid weight loss is weight loss of more than 1.5 to 2 pounds per week or weight loss of more than 1 percent of body weight per week..." Potential health problems associated with rapid weight loss, according to Medical-Surgical Nursing, 6th ed., Vol. 2, by Lewis, Heitkemper, and Dirksen, include hair loss, loose teeth, peridontal disease, increase in the incidence of stomach ulcers, diarrhea, decreased blood pressure and heart rate, [MEDICAL CONDITIONS], enlargement of the [MEDICAL CONDITION], increase in the number of infections, depression, confusion, decreased reflexes, paresthesias of hands and feet, [MEDICAL CONDITION], motor weakness, nocturia, decreased urinary output, and an increased susceptibility to respiratory infections. A Meal Intake Detail Report, dated 9/17/11 through 3/14/12, documented that Resident #8 either refused or consumed less than 50-percent of breakfast on 48 occassions between 9/29/11 and 3/12/12; lunch on 81 occasions between 10/3/11 and 3/14/12; dinner on 85 occasions between 9/27/11 and 3/14/12; and bedtime snacks on 110 occasions between 9/18/11 and 3/14/12. NOTE: The Meal Intake Detail Reports and the above data illustrated that Resident #8 either refused or consumed less than 50-percent of all meals - breakfast, lunch, and dinner - on 11/21/11, 12/2/11, 12/15/11, 12/26/11, 12/30/11, 1/9/12, 1/18/12, 1/23/12, 2/8/12, 2/10/12, 2/13/12, 2/14/12, 2/23/12, 2/28/12, 3/5/12, 3/6/12, 3/7/12, and 3/8/12. The above data also illustrated that Resident #8 either refused or consumed less than 50-percent of at least two meals on 10/3/11, 10/4/11, 12/7/11, 12/22/11, 12/27/11, 12/29/11, 12/30/11, 1/31/12, 2/11/12, 2/24/12, 2/26/12, 3/1/12, 3/9/12, and 3/12/12. No data was provided by the facility for breakfast on 9/18/11; lunch on 9/18/11, 10/8/11, 1/24/12, 2/2/12, 2/3/12, 3/4/12, and 3/9/12; dinner on 11/2/12, 1/26/12, 2/1/12, 2/2/12, 2/3/12, 2/26/12, and 2/29/12; and bedtime snack on 11/2/11, 1/26/12, 1/28/12, 1/30/12, 2/1/12, 2/2/12, 2/3/12, 2/26/12, and 2/29/12. Nutrition Progress Notes for Resident #8 documented the following: * 6/28/11: "Skin DTI (deep tissue injury) low back/sacrum. 6/21 wt (measured) 157.6 (pounds). Diet downgrade (to) Dys(phagic) 1/NTL/CCHO (concentrated carbohydrates). Avg (Average) intake (approximately) 75%. 6/2 - [MEDICATION NAME] slightly (down at) 3.0. Started multivitamin (with) min(eral) (and) Vit(amin) C to aid healing. Will monitor healing process. (No changes at) this (time)." * 7/4/11: "Unst(aged) sacral area cont(inues). 7/12 weight (at) 132.6 (pounds). Significant (drop) since admit. Diet: Dys 1/NTL/CCHO. Avg 77% intake (after) week. Will add (increased) Kcal/protein supplements - MP 2.0 (between) meals. Healing as goal. Continued wt (loss) (not) desired." * 8/9/11: "Coccyx/buttocks wounds cont(inue). (Plus sign) MVI (multivitamin) (with) min(erals). (Plus sign) Vit(amin) C. (Plus sign) MP 2.0. 8/2 wt (at) 137 (pounds). 8/8 (weight at) 136 (pounds). Significant (weight loss after) month. Diet: Dys 1/NTL/CCHO. (Approximately) 75% avg intake (at) meals. Recommend liberalized diet to D/C (discontinue) CCHO. Add EF ([MEDICATION NAME] foods). Cont(inue) MP 2.0 - Wt (loss not) desired. Healing as goal." * 8/22/11: "Current diet: dysphagia I NTL. Enhanced food program. (Weight down) 13% (over) 60 days. Dependant (sic) (with) feeding; eats in MDR. PO intake 70%. Within IBW range. Continue to monitor." * 8/31/11: "8/29 (weight at) 137.4 (pounds). Stable (after) mo(nth). Following healing - sacral/buttocks ulcers continue 'Kennedy ulcers' - tolerates liberalized diet cont(inue) Kcal/prot (caloric/protein) EF ([MEDICATION NAME] foods) (and) MP (Med Pass) 2.0. Avg (Average) intake (after) week (approximately) 71% (and) 1200 ml fluids per CT (unknown). Wt (Weight) maint/healing remain goal." * 9/19/11: "Stg IV sacrum continues (plus) perineum areas. (No changes) to diet. (Approximately) 75% avg intake ... (with) assist (at) meals. (No) new labs. 9/14 wt (at) 136.6 (pounds). Sig(nificant) (weight loss) since admit. Cont(inue) (illegible) (after) month. Will cont(inue EF, MP 2.0, MVI (with) min(erals), Vit. C. (Increase) MP 2.0 to TID (three times daily)." * 10/5/11: "Open areas cont(inue): sacral/buttocks. 10/5 wt (at) 131 (pounds). Cont'd (Continued) slow wt (loss) despite nutr(itional) interventions: liberalized diet, EF, MP 2.0 TID. Avg 66% intake (after) week. (Increased) needs to aid healing. Recommend pharm(acy) eval(uation) - consider app(etite) stim(ulator) ([MEDICATION NAME]) to (increase) PO (oral) intake/Kcals/prot(ein)." * 11/7/11: "Monitoring monthly (illegible) healing process goal of wt maint as well. Hx/o (History of) wt (loss). (No) sig(nificant) (changes) this month." * 12/17/11: "Sacral/perineum u/c (unchanged). Continue. (No changes) to diet/supplements. 68% avg intake (after) week. Healing issues (Kennedy ulcer). 12/6 wt stable (at) 134.8 (pounds). Still (above) IBW range. Will cont(inue) (increased) Kcal/protein interventions." * 12/20/11: "IDT (Interdisciplinary Team) note for trigger of report. 16.16% weight loss in past 180 days. RD (Registered Dietitian) aware (and) assessed. MD (Physician) (and) family aware of weight loss. Will continue weekly weights until weight stabalizes (sic)." * 2/6/12: "Weight up since (after) month - on (increased) Kcal/prot interventions. Also EF (and) MP 2.0 are (above) CHO (carbohydrate). Recommend keep diet liberal (with) no CHO restriction in effort to (increase) PO diet/intake. Weight stability to aid healing as goal." * 2/16/12: "IDT review of wt. loss. Resident noted (with) a 3.9% wt. loss in one wk (week). Current wt is 123.8 (pounds) on 2/6 (and) 126.6 (pounds) on 2/13. Resident averages 43.3% (consumption) of meals over 7 days. Resident currently receives enhanced foods (with) meals, Med Plus 2.0 4 ox (ounces) QID, multivit(amin) (with) minerals (and) Vit(amin) C. Resident is on wkly (weekly) wts. RD referral initiated. Resident continues (with) Kennedy's ulcer to sacrum (with) very limited healing. Resident IBW range is 99-121 (pounds), resident wt is fluctuating. Will continue current interventions (and) re-evaluate as needed." * 3/5/12: "Sacral/buttocks ulcers continue. Stg 4/Kennedys. 2/28 wt (at) 123 (pounds). EF. MP 2.0. MVI (with) min(erals). Vit(amin) C. Tolerates Dys 1 textures. Avg intake (approximately) 63% (at) meals (after) week. Healing remains goal. Is (at) high end IBW range, but weight maint(enance) also a goal as had hx/o sig(nificant) wt (loss). Kitchen to cont(inue) (increased) Kcal interventions (and) continue the MP 2.0 4x/d (four times daily)." On 3/14/12, at 11:00 a.m., the Registered Dietitian (RD) was interviewed. When asked what interventions, other than increasing MedPass 2.0 from twice daily to four times daily, were put into place to help stem the resident's continued weight loss between 8/31/11 and 3/14/12, the RD stated, "I feel like she's been watched." When informed that the resident's medical record did not include a response from the pharmacy or any documented follow-up by the facility, the RD stated, "They didn't start the [MEDICATION NAME]." When asked why the appetite stimulant was not started, the RD stated, "I don't know." On 3/15/12, at 7:30 a.m., the Administrator provided a typed statement to surveyors. That statement documented, in part, "The resident admitted from the hospital with a [DIAGNOSES REDACTED]. In review of the time period of 9/6/11 through 3/6/12, the resident experienced fluctuating weights ranging from 136 (pounds) to 126.4 (pounds). During this period, the resident had the following interventions in place to address weight variances: moved to restorative dining until successfully able to feed self with set-up and cueing (no documentation provided), MedPass increased (twice), weekly weights, food preferences reassessed (no documentation provided), daily review of food/fluid intake with IDT intervention as indicated, enhanced foods, liberalized diet, IDT review of weight variances with communication to family and physician for necessary/suggested recommendations (no documentation provided that family was asked for ideas/suggestions), (and) initiation of new medication to decreased mood/behavior triggers that may have interfered with PO intake. Throughout this period the resident was treated for [REDACTED]. The resident prefers med pass as her drink of choice, providing exceptional nutritional value. The resident's meal monitors demonstrate a consistent pattern of PO intake greater than 50% per meal per month. The (RD) evaluated the resident a minimum of monthly to address nutritional needs and monitor wound healing. The IDT identified the resident's weight loss and per our policies, reviewed the resident, interventions and progress through IDT review. IDT reviews were conducted 3 different times during the above stated period." Resident #8 was admitted to the facility with a known history of [MEDICAL CONDITION]. Since admission to the facility, the resident has experienced significant and severe weight losses, most notably a 9.7-percent loss of her total body mass in one month. The facility put into place a number of interventions between the time of the resident's admission to the facility in May 2011 through early August 2011. However, the only interventions put into place to help stem Resident #8's rapid weight loss between September 2011 and March 2012 was an increase in MedPass 2.0 supplement from twice daily to three times daily in September, and from three times daily to four times daily in February. The facility failed to obtain a medication review in an attempt to identify possible alternate medication therapies to address loss of appetite, follow through on a request for an appetite stimulant, address the resident's steadily declining consumption of meals by providing increased eating assistance or professional assessment of the feeding assistance being given, attempting quieter or more social dining settings, or increasing the number of meals and types of food offered to the resident. The facility failed to adequately intervene to help the resident avoid weight losses over a six month period, including a one month period during which Resident #8 experienced a 9.7-percent "severe" loss of total body mass.

Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure residents at risk for pressure ulcers did not develop multiple avoidable ulcers. This was true for 3 of 4 residents sampled for pressure ulcer prevention and treatment (#s 1, 4, and 7). Resident #4 was harmed when he developed 2 Stage II pressure ulcers on his buttocks in [DATE]; the facility failed to implement individualized and adequate interventions such as increased repositioning frequency to prevent pressure ulcers from developing for a quadriplegic resident who required an elevated head of bed (HOB) due to a [MEDICAL CONDITION] and tube feeding. Resident #1 was harmed when she developed bilateral heel pressure ulcers in [DATE]: a) the facility failed to implement interventions after the resident fell and had limited mobility which resulted in a pressure sore on the left heel, and b) failed to adequately monitor the resident to prevent a second pressure ulcer from developing on the right heel. In addition, Resident #7 developed a pressure ulcer on his left ankle in [DATE], due to poorly fitted shoes. Findings include: 1. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's [DATE] Admission MDS assessment coded: * No speech; sometimes understood; sometimes understands others * Modified independence with cognitive skills for daily decision making * Total dependence on 2 or more staff with physical assistance required for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing * Impaired range of motion on both sides, upper and lower extremities * External urinary catheter, occasionally incontinent of bowel, and toileting program in use * Pressure reducing device for chair and bed, and surgical wound care * The resident did not have any pressure ulcers CAA responses associated with the [DATE] MDS assessment documented that the resident, "has HOB elevated for (shortness of breath and to help with secretions).... Is in a functional quadriplegic state and is requiring a tube feeding and ([MEDICAL CONDITION]).... Is currently using a G tube (percutaneous endoscopic gastrostomy) for meds and feeding...." Treatments and other factors that could cause complications or increase risk included "Functional limitation in range of motion (G0400), Head of bed elevated most or all of the time, Bedfast (G0800)." The resident's [DATE] Plan of Care, most recently updated [DATE], documented: * Braden Risk Assessment Score: High Risk (,[DATE]) . * Skin integrity at risk related to central pontine myelinolysis, bowel incontinence, bladder incontinence * Areas of impairment: Stage II, right buttock * Goal: Will remain free of open areas, and will demonstrate healing without signs or symptoms of infection. * Interventions included: - Increase frequency of turning; maximal remobilization - Manage moisture, nutrition, friction and shear - Use commercial moisture barrier; use absorbent pads or diapers that wick and hold moisture; address cause if possible - Keep skin clean, dry, and free of body wastes, perspiration, and wound drainage - Implement an individualized turning schedule if applicable - Yellow Dot Program (reposition every 2 hours) - Increase frequency of turning if area of redness is non-blanchable. - Monitor wound weekly and PRN - See Skin Grid - Pressure/[MEDICAL CONDITION] Ulcer/Other - Change incontinent product PRN - Elevate HOB/extremity 30 degrees or (less) - Anticipate needs - Provide diet as ordered: [MEDICATION NAME] 1.5 at 95 ml/hr for 16 hours/day The resident's [DATE] Quarterly Comprehensive Care Plan Review Summary documented for Skin/Wound: * Resident Lifting, Transferring and Repositioning Data Collection updated and reviewed; Skin Integrity Assessment Prevention and Treatment Plan of Care reviewed and updated; care plan goal reviewed and updated. * Weekly Skin Assessment reviewed; no skin/wound issues since last review; no change in status since last review. * "Resident remains NPO (nothing by mouth), receives [MEDICATION NAME] (at) 95 ml/hr (milliliters per hour) for 16 (hours per day). Resident is incontinent of bowel (and) bladder. Resident is non-verbal. (Occasionally) has pain in neck controlled (with) [MEDICATION NAME]. No falls this quarter. Resident (without) skin issues (and) on a turning schedule." The resident's Care Delivery Guide for CNAs, which was based on the Plan of Care and taped inside the closet door in his room, documented: * Assist positioning every 2 hours, with 2 staff * Turn at least every 2 hours in bed * HOB (less than or equal to) 30 degrees * Tube feeding, HOB elevated less than or equal to 30 degrees NOTE: Potter and Perry's Clinical Nursing Skills and Techniques, 7th Edition, documented the following Evidence-Based Practice Trends: * Endotracheal Tube Care - "Best practice guidelines indicate the following interventions are advantageous in preventing (Ventilator-Associated Pneumonia): 1. Elevating the head of the bed at 30 to 40 degrees to prevent aspiration. 2. Changing patient position every 30 minutes to decrease risk for atelectasis and [MEDICAL CONDITION] infections.... 5. Carefully monitoring patient for aspiration when enteral feedings are infusing." * Enteral Nutrition - "Preventive measures have been studied , but incidence of aspiration remains high, and patients with altered mental status are at highest risk..... Head of bed elevation to a minimum of 30 degrees is a simple method to keep the risk for aspiration at a minimum." FEDERAL GUIDELINES recommend: "The care plan for a resident who is reclining and is dependent on staff for repositioning should address position changes to maintain the resident's skin integrity. This may include repositioning at least every 2 hours or more frequently depending upon the resident's condition and tolerance of the tissue load (pressure). Depending on the individualized assessment, more frequent repositioning may be warranted for individuals who are at higher risk for pressure ulcer development.... Elevating the head of the bed or the back of a reclining chair to or above a 30 degree angle creates pressure comparable to that exerted while sitting, and requires the same considerations regarding repositioning as those for a dependent resident who is seated. Many clinicians recommend a position change - "off loading" hourly for dependent residents who are sitting or who are in a bed or a reclining chair with the head of the bed or back of the chair raised 30 degrees or more." Resident #4's February 2011 physician's orders [REDACTED]. * [MEDICATION NAME] 1.5, 95 ml/hr on at 4 PM, off at 8 AM * Free water, 250 ml [MEDICATION NAME] every 6 hours * [MEDICAL CONDITION] care every day * Weekly skin assessment on Monday evenings The resident's Braden Risk Assessment Scale documented a score of 11, where ,[DATE] equaled High Risk, on [DATE], [DATE], [DATE], [DATE], and [DATE]. Nursing Progress Notes (NPN) for Resident #4 from [DATE] through [DATE] were reviewed, and documented numerous entries in which the resident was turned or repositioned "q2" (every 2 hours). Beginning [DATE], NPN documented that Resident #4 spent increased time in a recliner or wheelchair, and the resident was repeatedly documented to be repositioned "q2" through [DATE]. The following are the only entries through [DATE] which documented repositioning frequency other than "q2" hours: * [DATE] at 3:15 PM - "Up in wheelchair for 1 hour...." * [DATE] at 7 PM - "Turning performed frequently." * [DATE] at 4:25 PM - "Sat in lobby and looked out window." * [DATE] at 11:38 PM - "Repositioned x3 (three times) today." * [DATE] at 12:10 AM - "HOB elevated." * [DATE] at 10:30 PM - "Turned (every 1 hour)." * [DATE] at 9:45 PM - "Position (changed every ,[DATE] hours)." * [DATE] at 7:30 PM - "Tilts (every 1 hour) to prevent skin breakdown." * [DATE] at 9:45 PM - "Repositioned (every ,[DATE] hours)." NPN documented the following related to pressure sores: * [DATE] at 7 PM - "Noted 1 x 2 open area on (right) buttocks, cleaned (and) dressed (with) Allevyn - appears St II+ (Stage II plus); (continue) to turn (and) reposition at least (every 2 hours)." * [DATE] at 11:45 PM - "Noted 2 small open areas on buttocks 0.5 cm x 1.5 cm on (right) inner gluteus and 0.25 x 1 cm on (left) inner gluteus; small reddened area on lateral (right) cheek and 0.5 cm x 0.5 cm blistered area to (left) thigh; cleansed areas on gluteus (and) applied Allyvn (sic).... Placed on alert and 24 (hour) report." * [DATE] at 1:30 PM - "Buttocks areas closed." * [DATE] (No time) - "Rechecked resident's skin for skin check (and secondary) to diarrhea (with intravenous antibiotics). No open areas noted to skin. Red areas to buttock (sic) are healthy, blanchable tissue. Instructed CNAs to use protective ointment to peri-area (secondary) to moisturizing quality. Continue (with every 2) hour turning (and increased) peri-care." NOTE: Turning frequency was not increased after the resident developed pressure sores, reddened areas, and diarrhea. * [DATE] at 10:40 PM - "(Dressings changed) both cheeks on buttocks Stage II areas." * [DATE] at 3:30 PM - Dressings (changed) to excoriation on (bilateral) buttock (sic)." * [DATE] at 10:30 PM - "Breakdown on coccyx stable." A [DATE] Accident/Incident Report documented for Resident #4: * "Noted 0.5 x 1.5 cm (centimeter) open area to inner (right) gluteus and 0.25 cm x 1 cm scabbed area to (left) gluteus. Small reddened area noted at base of (right) cheek and 0.5 cm x 0.5 cm blistered area noted to (left) inner thigh." * Immediate action taken: "Removed brief. Cleansed open areas on buttocks and applied Allyvn (sic) (dressings), ensured resident repositioned (every 2 hours). * Final Disposition - "Resident placed in brief, removed excoriated, healed tissue revieling (sic) healthy, pink blanchable tissue no open areas, Allevyn adhesive placed to areas for [MEDICATION NAME]. (Care Plan) updated. Staff educated, MD (and) family notified, alert charting (and) therapy referral initiated...." This section was dated [DATE]. On [DATE] at 2:00 PM, the RCM (resident care manager) was interviewed about the resident's pressure sores. She stated that the "reddened" areas on the resident's buttocks were caused by diarrhea from his IV (intravenous) antibiotics - "IV [MEDICATION NAME] was started after oral antibiotics. He got diarrhea and his buttocks were excoriated, very red; horrific diarrhea. I checked him in the morning; it was all blanchable and the resident denied pain. The next day I educated the nurses about the ,[DATE] note. When I went back and cleaned the tissue off, there were no open areas." She then provided the resident's [DATE] MAR and bowel records, which documented: * Diarrhea on [DATE], 1 time from 6:30 AM to 2:30 PM * Diarrhea on [DATE], 1 time from 6:30 AM to 2:30 PM * [MEDICATION NAME] 3.375 milligrams IV every 6 hours, [DATE] at 12 PM through [DATE] at 6 PM. * Diarrhea from [DATE] through [DATE], [DATE], and [DATE]. NOTE: NPN documented diarrhea which was not documented in the bowel record, on [DATE]. No other diarrhea was documented in the resident's medical record. NOTE: The resident's pressure sores were documented to be present on [DATE] and [DATE]. He had documented diarrhea one time ([DATE]) in the 5 days prior to the development of the pressure sores, and the [MEDICATION NAME] was started after the pressure sores developed. The resident's Treatment Administration Records for November and [DATE] documented that weekly skin assessments were to be done on Monday evenings. A plus sign (+) would indicate a new problem area, and a negative sign (-) would indicate no new problem areas. There was no entry for the [DATE] assessment. All other assessments ([DATE], [DATE], [DATE], [DATE], and [DATE]) had a negative sign (-) with a nurse's initials, to document that there were no new problem areas. On [DATE] at 9:40 AM, the RCM (resident care manager) was interviewed about Resident #4's skin assessment documentation. She stated that the [DATE] assessment was "missed," and that the [DATE] assessment indicated that there were no new areas "because (the nurse) had already documented it on an incident report; there were no 'new' or 'undocumented' areas." She acknowledged that best nursing practice would be to document on the Treatment Administration Record Flowsheet that a change had occurred between the [DATE] and [DATE] assessments. When asked to provide the Skin Grid - Pressure/[MEDICAL CONDITION] Ulcer/Other forms, which was listed as an intervention on the resident's Care Plan, she stated that she did not complete one. She referred the surveyor to her [DATE] NPN entry and stated that when she assessed the resident on [DATE], "there were no open areas." Resident #4's Significant Other/Power of Attorney was interviewed by telephone on [DATE] at 8:30 AM. She stated, "I think they try really hard to position him every 2 hours, but sometimes he's not in good alignment. Some CNAs are really good, some not. I asked (the facility) to educate (the CNAs) on positioning a quadriplegic." On [DATE] at 8:50 AM, Social Services and Activities staff were informed of her statements; they stated they would advise the DON and Administrator, and assist to schedule the requested training. Resident #4, a quadriplegic with a [MEDICAL CONDITION] and tube feedings, required an elevated HOB and was both care planned for and documented to be repositioned every 2 hours; he was harmed when he developed 2 Stage II pressure ulcers on his buttocks. Federal guidelines and evidence based practice document that such risk factors demand much more frequent repositioning. Regardless of whether or not the RCM believed the resident had developed open pressure ulcers as documented (with measurements) in the NPN, she did assess and document the resident's buttocks to be "excoriated," and described them to the surveyor as "reddened". The resident's repositioning frequency was never increased after a problem area was identified. 2. Resident #1 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly MDS, dated [DATE], documented that the resident: * was severely cognitively impaired, * did not have any documented behaviors, * required extensive assistance of two staff for bed mobility, dressing, ambulation, personal hygiene and bathing. * was frequently incontinent of bowel and bladder, * did not have a pressure sore (M0210), and * did not have a stasis ulcer (M1030). The most recent significant change MDS assessment, dated [DATE], documented that the resident: * had short and long term memory problems, * had moderate impairment for decision making, * had one to three times a week behaviors of wandering, resisting care and verbal abuse, * required extensive assistance of one to two staff for bed mobility, dressing, ambulation, personal hygiene and bathing. * was frequently incontinent of bowel and bladder, and * did not have a pressure sore. According to an "Incident/Accident Report" dated [DATE] the resident had a fall at 4:00 a.m. As a result of the fall the resident fractured the left (L) arm. The resident went to the emergency room and the arm was put in a sling and swath. Prior to the fall and since the [DATE] assessment the resident had been receiving therapy for strengthening. Staff noted and data reflected on the "Compressed ADL Report" printed [DATE] at 9:08 a.m. that the resident was ambulating prior to the fall. As a result of the fall the resident no longer ambulated. Two days prior to the fall the staff documented on the facility "Compressed ADL Report" the following, Shift 1 = 10:30 p.m. to 6:30 a.m., Shift 2 = 6:30 a.m. to 2:30 p.m., Shift 3 = 2:30 p.m. to 10:30 p.m.: * [DATE] for bed mobility: Shift 1 = independent and no assistance provided, Shift 2 = independent and no assistance provided, Shift 3 = supervision and no assistance provided. * [DATE] for locomotion: Shift 1 = independent and no assistance provided, Shift 2 = independent and no assistance provided, Shift 3 = supervision and set up help only. * [DATE] for bed mobility: Shift 1 = independent and no assistance provided, Shift 2 = supervision and no assistance provided, Shift 3 = independent and no assistance provided. * [DATE] for locomotion: Shift 1 = independent and no assistance provided, Shift 2 = supervision and set up help only, Shift 3 = independent and no assistance provided. The resident fell on [DATE], and after the fall the resident required increased assistance for bed mobility and locomotion about the facility. The "Compressed ADL Report" documented: * [DATE] for bed mobility: Shift 1 = Extensive assistance of two + persons physical assist, Shift 2 = Extensive assistance of two + persons physical assist, Shift 3 = Extensive assistance of one person physical assist. * [DATE] for locomotion: Shift 1 = Activity did not occur Shift 2 = Extensive assistance of one person physical assist, Shift 3 = Independent and set up help only. * [DATE] for bed mobility: Shift 1 = Activity did not occur, Shift 2 = Extensive assistance of two + persons physical assist, Shift 3 = Extensive assistance of two + persons physical assist. * [DATE] for locomotion: Shift 1 = Activity did not occur Shift 2 = Extensive assistance of one person physical assist, Shift 3 = Independent and no setup or help from staff. * [DATE] for bed mobility: Shift 1 = Activity did not occur, Shift 2 = Extensive assistance of two + persons physical assist, Shift 3 = Extensive assistance of two + persons physical assist. * [DATE] for locomotion: Shift 1 = Activity did not occur, Shift 2 = Extensive assistance of one person physical assist, Shift 3 = Extensive assistance of one person physical assist. * [DATE] for bed mobility Shift 1 = Extensive assistance of one person physical assist, Shift 2 = Total dependence of two + persons physical assist, Shift 3 = Extensive assistance of two + persons physical assist. * [DATE] for locomotion: Shift 1 = Activity did not occur, Shift 2 = Supervision and no physical help from staff, Shift 3 = Extensive assistance of two + persons physical assist. On [DATE] the evening LN documented in the nurse "Progress Notes" that "heels floated (secondary to) c/o (complaint) burning pain... (daughter) here, noted R (right) heel blister (with) soft heel cap - both feet (elevated) heels floated off bed and w/c (wheelchair)... protective drsg (dressing) (secondary to) weeping of blister." Note: The resident went from [DATE] to [DATE] without heels floated and had declined from independent to needing assistance of one to two staff for bed mobility. On [DATE] the IDT (Interdisciplinary Team) met and documented, "Resident assessed r/t (related to) c/o pain. Observed fluid filled blister - refer to wound assessment for measurement. Is currently on case load (with) ARNP-CWCN (Advanced Practice RN - Certified Wound Care Nurse). RD assess for nutrition/dietary/fluids completed. Now in w/c with foot pedals, care plan updated to reflect current ADL needs...." The "Skin Grid - Pressure/[MEDICAL CONDITION] Ulcer/Other" form, dated [DATE], documented: Site - Rt (right) back of heel, Stage - II (two), Pressure checked, Dimensions in cm (centimeter) - Length 3.3 cm, Width 2.5 cm Depth (no documentation), Drainage - Scant. The "Accident/Incident Report" final disposition dated [DATE] documented, "Res(ident) presented (with) fluid filled blister to back edge of Rt heel, scant serosang(unous) drainage, blister, cont(inues) (with) fluid filled and is intact. Res(ident) had been propelling self in w/c using feet by digging heels into floor to move, and had been independent (with) bed mobility. Has had a recent (change) and doesn't move much in bed. Now has foot pedals and req(uires) assist (with) w/c propelling. Heel pro placed in bed and blue boots except for transfers..." The resident's care plan for "Skin Integrity Assessment: Prevention and Treatment Plan of Care" documented on [DATE] an intervention of,"heel pro in bed/blue boots to bilat(eral) feet, may remove for transfers." The CNA tool called the "Care Delivery Guide" had the same addition to it but there was no date when the change occurred. The facility documentation on the "Turn and Reposition Chart Detail Report" documented from [DATE] through [DATE] for all shifts, "Was Resident turned and repositioned per the plan of care?" and all documentation was "yes." The CNA tool "Care Delivery Guide," dated [DATE], documented that the resident "Positions per self." No changes were made to this notation. The nursing "Progress Notes" were reviewed for documentation about the pressure sore and cares provided with the following documentation noted: [DATE] - evening- "up in w/c (with) feet booties protecting feet, in bed (after) dinner...R heel drsg changed (with) zero drainage on old dressing..." [DATE] - 9:30 p.m. - "no c/o pain...stayed in bed t/o(throughout) shift. Cares provided q (every) ,[DATE] hrs (hours) ate dinner in room...." [DATE] - 9:30 p.m.- "...stayed in bed t/o shift (with) cares provided q ,[DATE] hours..." [DATE] - 4:30 a.m. - "...repositioned in bed q 2 hrs...." [DATE] - evening - "...no drainage on blister heel drsg R heel...." [DATE] - evening - "...blister dry no redness around it R heel, heels floated off mattress...." [DATE] - evening - "...R blister dry, intact...." [DATE] - 6:30 a.m. - "Res has new skin issue which was found by RN (name). Pt (patient) has a 4 cm X 5 cm blister on L heel. Covered with dressing and floated heels. Educated Pt on rubbing heels on bed...." [DATE] - 1:00 p.m. - "...Drsg to both R heel and L ankle CDI (clean, dry, intact)..." [DATE] - 10:00 a.m. - "Res discharged to (hospital) for surgery on L shoulder...." The "Accident/Incident Report" dated [DATE] documented,"...New large blister on back of (Resident #1) L heel. Pt has similar blister on R heel." The "Final Disposition," dated [DATE], documented,"Res (with) recent (decreased) mobility r/t previous fall, went out to hospital ,[DATE] for surgery on shoulder. Res has blue boots and heel pro in place prior to surgery. Res readmitted [DATE] from (hospital), air mattress (with) bolster sheet and blue boots in place upon return. Bilat heels (with) dry brown blister area to back of heels, skin intact and fluid completely reabsorbed." The DON and RCM were interviewed on [DATE] at 2:30 p.m. and indicated the facility had not completed a "Skin Grid - Pressure/[MEDICAL CONDITION] Ulcer/Other" form for the pressure sore on the L heel. The "In House Pressure Ulcer Weekly Report," dated [DATE], documented: * Date Acquired = [DATE], * Stage = II, * Visualized Stage = III, * Size L/W/D = 3.2 x 2.8 (cm), (depth = no documentation) * Site = R heel, * Drainage Exudate Type = None, * Treatment = Intact fluid filled blister, [MEDICATION NAME] island dsg (dressing) change daily. The resident had been discharged to the hospital before the next report was due which would have included the sore on the L heel. The DON and RCM were interviewed on [DATE] at 2:30 p.m. The DON indicated that after the resident fractured her arm her mobility had decreased. The resident was ambulating prior to the fracture and now was restricted to the wheelchair. The resident spent a lot of time in bed. When she was up in the wheelchair she would use her feet to propel the w/c around the facility. The DON demonstrated how the resident moved the wheelchair by digging her heels into the carpet to pull the chair forward. The facility failed to prevent the two pressure sores on the residents heels by not: * Floating the heels after the resident fractured her arm and spent more time in bed. * Revising the care plan to increase assistance more than "q ,[DATE] hours." * Increasing the turning and positioning frequency after the resident fractured her arm and spent more time in bed. * Monitoring the resident's change in mobility to assure the resident did not develop skin issues. * Monitoring the resident to assure she was not "rubbing heels on bed" and assuring the resident was wearing the "blue boots" when in bed/wheelchair. 3. Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent quarterly MDS, dated [DATE], documented the resident: * Was severely cognitively impaired, * Required extensive assistance of one staff for transfers, ambulation, dressing, personal hygiene and bathing, and * Was frequently incontinent of bowel and bladder. The facility completed an "Accident/Incident Report" on [DATE] for Resident #7 that documented, "Shower Aide found abrasion on (upper) medial L Ankle 4 x 2 cm reported to RCM (resident care manager). Diabetic shoes taken to laundry, instructed to have res wear slippers until healed." The Final Disposition, dated [DATE], documented, "...Resident wearing black diabetic shoes, tounge (sic) bent et (and) rubbed residents L upper medial ankle/shin causing a blister that opened. Shoes removed et slippers in place..." The DON and RCM were interviewed on [DATE] at 2:30 p.m. and indicated the facility failed to complete a "Skin Grid - Pressure/[MEDICAL CONDITION] Ulcer/Other" form on the area. The resident's sore was not on the weekly "In House Pressure Ulcer Weekly Report." Nursing "Progress Notes" documented: * [DATE] - 2:00 p.m.- "New open area found to L medial ankle 4 cm X 2 cm diabetic shoes taken Res to wear slipper until healed." * [DATE] - 9:30 p.m. - "No c/o pain or discomfort noted d/t (due to) area on L medial ankle. No s/sx (sign/symptom) of infection." * [DATE] - 9:30 p.m. - "No c/o pain or discomfort noted d/t area on L medial ankle...." * [DATE] - 2:40 p.m. - "...No s/sx of infection to L medial ankle." * [DATE] - 9:30 p.m. - "...area to L medial ankle (with) no s/sx of infection...." * [DATE] - 2:45 p.m. - "DSG R ankle CDI...." * [DATE] - 9:30 p.m. - "...R ankle (with) no s/sx of infection...." * [DATE] - 2:30 p.m. - "...DSG (changed) to R ankle, healing well." * [DATE] - 2:00 p.m. - "...DRSG to R ankle intact." * [DATE] - 2:50 p.m. - "Drsg intact to R ankle." * [DATE] - 12:30 a.m. - " Drsg to left ankle clean dry and intact. (no) c/o pain or discomfort...." * [DATE] - 1:35 p.m. - "...Drsg changed to R ankle would (sic) healing well...." * [DATE] - 2:15 p.m. - "...Drsg to R foot CDI no c/o pain or discomfort." * [DATE] - 9:45 a.m. - "Allyuin (sic) changed to R ankle, wound appears smalled, (sic) Small amount of brown drainage no odor." * [DATE] - 2:30 p.m. - "...Drsg to medial R ankle (changed)...." * [DATE] - 9:40 p.m. - "...Lt (left) ankle dressing (without) problems...." * [DATE] - E (evening) - "R ankle healing, Allyn (sic) drsg applied...." * [DATE] - 1:15 p.m. - "Drsg to R ankle CDI...." * [DATE] - 1:20 p.m. - "Wound to R ankle resolved...." Resident #7 care plan for "Integrated Assessment: Prevention and Treatment Plan of Care" had an intervention added on [DATE] that documented: * "TED (therapeutic emboli device) hose, socks et slippers, no diabetic shoes." * "Assess L Ankle/Shin for s/s infection. Leave open to air until resolved." The DON and RCM (resident care manager) were interviewed on [DATE] at 2:30 p.m. The RCM stated the sore occurred because the resident's diabetic shoes had been laundered. The tongue had become hard due to the laundry. The resident wore the shoes and the hard tongue rubbed on the front side of the left foot causing a blister. The DON indicated that the sore was not reported to the skin committee, and that was why it was not monitored as other sores were. The facility had failed to: * Identify that the sore was a pressure sore caused by a damaged shoe, * Monitor the healing and staging of the sore, and * Clearly document in the nursing notes the location of the sore.