Every finding on record at McCall Rehabilitation and Care Center

Based on record review and observation it was determined the facility failed to ensure a qualified individual was employed with the knowledge and skill set to carry out the function of food and nutrition services. This deficient practice created the potential to affect 35 residents who consumed food prepared by the facility. This placed residents at risk for undetected weight loss and adverse health outcomes when the facility did not employ a qualified individual to meet all resident nutritional needs. Findings include: The facility's Quality Assurance and Performance Improvement (QAPI) meeting minutes, dated January 2025, documented under dietary services, the facility had a goal to enroll the Dietary Manager (DM) into a dietary manager certification training by the next quarter. The facility's QAPI meeting minutes dated April 2025, included confirmation of enrollment to the dietary manager certification training. On 7/23/25 at 10:43 AM, the DM stated she is not a Certified Dietary Manager. She stated she was currently enrolled in a training program and had 11 months left before she completed the program. On 7/24/25 at 9:56 AM, the Administrator stated the facility did not have a qualified individual with the knowledge and skill set required to meet the nutritional needs of residents.

Number of residents sampled:Number of residents cited:SDP= GenesisUniverse= Facility wide Concerns with Food and Nutrition Services regarding kitchen sanitation. Based on observation, staff interview, and Food Code review, it was determined the facility failed to ensure the kitchen equipment was maintained in sanitary condition and food was handled in a safe and sanitary manner. These deficient practices created the potential to affect 35 residents who consumed food prepared by the facility. This placed residents at risk for potential food contamination and adverse health outcomes, including food-borne illness. Findings include: The FDA Food Code Section 4-601.11 (C) Cleaning of Equipment and Utensils, documented nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, food residue, and other debris. 1. On 7/23/25 at 10:59 AM, during a kitchen inspection a black kitchen aid mixer was observed sitting on a counter with white encrustations. On 7/23/25 at 11:05 AM, the DM stated the mixer was not in sanitary condition. 2. On 7/23/25 at 11:05 AM, a kitchen cabinet near the thawing station was observed to store clean stainless-steel pans. The cabinet was noted to have dust like particles with dry noodles on the surface where pans were placed. One of the stainless-steel covers was observed with yellow dry encrustations. On 7/23/25 at 11:07 AM, the DM stated the pans were not stored under sanitary conditions. 3. On 7/24/25 at 8:07 AM, during a tray line observation the DM was observed touching her clothing then continuing to serve ready-to-eat food onto a meal tray. The tray was then placed in the food cart for delivery. No observation of hand hygiene was noted. On 7/24/25 at 8:18 AM the DM stated it was unsanitary to touch per personal clothing and continue touching ready-to-eat food with no hand hygiene in between. The FDA food code section 3-304.15 (A) Gloves, Use Limitation, documented if used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. 4. On 7/24/25 at 8:25 AM, during a tray line observation the DM was observed wearing gloves and cracking two eggs on the stove top griddle. She then proceeded to cut toast and place it on a plate without changing her gloves. The DM covered the plate and placed it on a resident tray, then placed the tray on a cart for delivery. No hand hygiene or glove changing was observed when going from raw uncooked food to ready-to-eat food. On 7/24/25 at 8:28 AM, the DM stated she did not change her gloves or perform hand hygiene when going from raw to cooked foods. She also stated she should have performed hand hygiene after placing the raw eggs on the stove top griddle.

Based on observation, staff interview, and policy review, and review of nationally recognized standards, it was determined the facility failed to ensure appropriate infection control measures were implemented for hand hygiene. These failures created the potential of exposing residents to the risk of infection and cross-contamination including COVID-19. Findings include: a. The facility's policy for Hand Hygiene, undated, documented, The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. The Centers for Disease Control and Prevention website, Hand Hygiene in Healthcare Settings under the tab Guidelines, accessed 6/22/20, stated: * Hands should be decontaminated or washed after removing gloves * Gloves should not be washed or reused On 6/16/20 at 2:47 PM, LPN #1 was wearing gloves at the nurse's cart and applied hand sanitizer to her gloved hands and rubbed her gloved hands together until the hand sanitizer was dry. LPN #1 then removed a disinfectant wipe and wiped down the nurse's cart while wearing the gloves. LPN #1 stated she was pretending there was a glove shortage and applied the hand sanitizer on her gloved hands. LPN #1 stated the facility did not have a glove shortage. There were two boxes of gloves on the wall next to the nurse's cart and one box of gloves above the nurse's cart. LPN #1 stated she received education regarding hand hygiene which included not to reuse gloves. b. The Centers for Disease Control and Prevention website, How to Wear Cloth Face Coverings, accessed on 6/22/20, stated: * Cloth face coverings are an additional step to help slow the spread of COVID-19 * The correct way to wear cloth face coverings was to put it over your nose and mouth and secure it under your chin * Don't touch the face covering, and, if you do, wash your hands On 6/16/20 at 2:50 PM, LPN #1 was wearing a cloth mask while talking. The mask dropped below her nose and her nostrils were exposed. LPN #1 readjusted the cloth mask above her nose and did not perform hand hygiene after touching her cloth mask. LPN #1 stated the cloth masks did not fit her correctly and this was the second one she had changed since the start of her shift. While LPN #1 was explaining the cloth mask did not fit her correctly, she readjusted the cloth mask to cover her nose five times. LPN #1 did not perform hand hygiene each time after touching her mask. LPN #1 then reached in her pocket and grabbed the keys to the nurse's cart and stated she was going to change masks. LPN #1 stated she should perform hand hygiene after each time she touched her mask. On 6/16/20 at 3:05 PM, the DNS stated the facility did not have a glove shortage and LPN #1 should not have applied hand sanitizer to her gloved hands. The DNS stated LPN #1 should have performed hand hygiene after each time she readjusted the cloth mask above her nose.

Based on policy review, review of grievance reports, employee record review, and staff interview, it was determined the facility failed to ensure its policies were implemented to protect residents from potential physical and/or psychosocial harm. This was true for 2 of 5 residents (#2 and #3) whose grievance reports were reviewed, and for 1 of 8 staff (RN #1) whose personnel files were reviewed for pre-employment background checks. This had the potential to place each of the 26 residents residing in the facility at increased risk for physical and/or psychosocial harm. Findings include: 1. The facility's Abuse policy, updated 4/2019, stated It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation .All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee .The investigation, and the results of the investigation, will be documented. The policy also documented investigations would include the following an interview with the person(s) reporting the incident; an interview with the resident(s); interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate; a review of the resident's medical records; an interview with staff members (on all shifts) who may have information regarding the alleged incident; interviews with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident; an interview with staff members (on all shifts) having contact with the accused employee; and a review of all circumstances surrounding the incident. This policy was not followed. The facility's Grievance Reports, dated 8/28/19 to 12/2/19, included allegations of potential abuse and neglect, as follows: a. A Grievance Report, dated 9/12/19, stated Resident #3 .saw (CNA #8) & resident 11B (sic). She believes that there was inappropriate sexual activity going on between them .(Resident #3) reports seeing some of the young, pretty CNAs flirting with resident (sic) 23B. She says they sit in his lap, hug and kiss him . b. A Grievance Report, dated 10/25/19, stated on 10/24/19 during the evening shift, RN #3 went into Resident #3's room with Resident #3's medication. The report stated My drawer was open, and she saw my white box with [MEDICATION NAME] gel. She said I couldn't keep it. I told her that (the DNS) said I could keep it in my drawer. I was also told I could keep my prescription shampoo. (RN #3) threw the box back into my drawer and then slammed my pills onto my bedside table. Some of the pills bounced off the table onto the floor. She turned and left the room .I don't want to deal with (RN #3). She is just nasty . The report stated the Administrator talked with Resident #3's roommate who witnessed the event and verified the incident. c. A Grievance Report, dated 11/18/19, stated Resident #2 reported They went to move her up in bed and used her arms rather than (sic) turn sheet .Resident with some discomfort to her right shoulder .Then she went on to say that (CNA #7) wasn't friendly and threw her gloves . The report documented 5 additional residents were interviewed and Resident #9 stated .new gal is a bit rough . and Resident #3 .says tall female aid is rough. She needs some skills. She does not want her to bathe her. d. A Grievance Report, dated 11/26/19, stated Resident #2 reported (LPN #2) has been nasty to every (sic) since I came here .She said she was mad because I rang the bell (call light) all the time. When asked about the reports and the facility's abuse policy, the LSW stated during an interview on 12/18/19 from 8:55 AM to 10:15 AM, the incidents were viewed as grievances and not allegations of potential abuse or neglect. The facility failed to implement their policy to thoroughly investigate and document all allegations of abuse and neglect. 2. The facility's Pre-Employment Investigations policy, revised 5/2014, stated If the applicant/employee receives approval through ICHU to be employed in a skilled nursing facility, those results shall be maintained in his/her confidential personnel file. The personnel files of 8 staff were reviewed for background checks. Seven records included evidence of ICHU background checks. However, documentation of a ICHU background check for RN#1 could not be found. RN #1's personnel record documented her date of hire was 10/15/19. When asked during an interview on 12/18/19 at 10:45 AM, the DNS stated she could not find documentation of a background check with fingerprints for RN #1. The facility failed to ensure their policy for pre-employment background checks was implemented for RN #1.

Based on policy review, review of grievance reports, and staff interview, it was determined the facility failed to ensure allegations of abuse, neglect, and misappropriation of resident property, were reported to the State Survey Agency within 24 hours for 5 of 5 residents (Residents #2, #3, #4, #7, and #8) whose grievance reports were reviewed. This resulted in the potential for adverse outcomes to residents whose abuse, neglect and misappropriation of resident property was not reported and investigated throughly. Findings include: The facility's Abuse policy, updated 4/2019, stated It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation . The policy included the following definitions: - Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in the definition of abuse, means the individual must have acted deliberately . - Mistreatment: inappropriate treatment or exploitation of a resident. - Misappropriation of resident property: the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongings or money without the resident's consent. - Neglect: the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. - Verbal Abuse: includes the use of oral written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representatives, or within their hearing distance, regardless of their age, ability to comprehend, or disability. The facility's Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment policy, revised 11/28/17, stated the facility would ensure all alleged violations were reported to the State Survey Agency. The facility's Grievance Reports, dated 8/28/19 to 12/2/19, included allegations of abuse, neglect, misappropriation of funds, and exploitation. The facility's Grievance Reports which included allegation of abuse, mistreatment, neglect and misapprorpriation of resident propertly did not include evidence the allegations were reported to the State Survey Agency, as follows: a. A Grievance Report, dated 8/28/19 at 4:45 PM, stated Resident #4 was .visibly upset .feeling very scared because she could not breath. She stated she was poorly positioned and her air was being cut off .(CNA #9) came in and repositioned her .She noted nurse, (LN #1) had been in the room as well, but was in a hurry. She did not seem to understand how frightened and upset (Resident #4) was. (Resident #4) told her she couldn't breathe. (LN #1) checked the oxygen and said it was working fine. She didn't understand that it was (Resident #4's) position that was restricting her breathing. The LSW reported to nurse (LN #1) and she requested (CNA #9) and another CNA go back to reposition (Resident #4) again. b. A Grievance Report, dated 9/12/19, stated Resident #3 .saw (CNA #8) & resident 11B (sic). She believes that there was inappropriate sexual activity going on between them .(Resident #3) reports seeing some of the young, pretty CNAs flirting with resident (sic) 23B. She says they sit in his lap, hug and kiss him . c. A Grievance Report, dated 10/1/19, stated Resident #8 stated About 3 weeks ago, I noticed that I had $300 missing out of my room .I reported it to (the Administrator). I did not file a police report because I thought I knew who was doing it. I thought it was a guy that visits residents (sic) in 21. This time .$100 was taken from my bedside table .I want to file a police report. (The Administrator) said he would call them for me. d. A Grievance Report, dated 10/25/19, stated on 10/24/19 during the evening shift, RN #3 went into Resident #3's room with Resident #3's medication. The report stated My drawer was open and she saw my white box with [MEDICATION NAME] gel. She said I couldn't keep it. I told her that (the DNS) said I could keep it in my drawer. I was also told I could keep my prescription shampoo. (RN #3) threw the box back into my drawer and then slammed my pills onto my bedside table. Some of the pills bounced off the table onto the floor. She turned and left the room .I don't want to deal with (RN #3). She is just nasty . The report stated the Administrator talked with Resident #3's roommate who witnessed the event and verified the incident and RN #3 was educated about her approach with residents. e. A Grievance Report, dated 11/26/19, stated Resident #2 had $40.00 in her pants pocket and suspected CNA #3 had taken it. The report stated money not found. Resident has been reimbursed by facility. Investigation completed + staff interviewed (CNA #3 and CNA #10). f. A Grievance Report, dated 11/26/19, stated Resident #2 reported (LPN #2) has been nasty to every (sic) since I came here .She said she was mad because I rang the bell (call light) all the time. The report stated She (LPN #2) has been counseled to work on customer service. She realized she needs to improve + will work on it. g. A Grievance Report, dated 11/18/19, stated Resident #2 reported They went to move her up in bed and used her arms rather than (sic) turn sheet .Resident with some discomfort to her right shoulder .Then she went on to say that (CNA #7) wasn't friendly and threw her gloves . The report documented 5 additional residents were interviewed and Resident #9 stated .new gal is a bit rough . and Resident #3 .says tall female aid is rough. She needs some skills. She does not want her to bathe her. h. A Grievance Report, dated 12/2/19, stated Resident #7 .saw an employee coming out of her room with some of her special diabetic lotions given to her by her daughter .The unidentified employee stated she was instructed to go through residents' rooms and remove excess toiletries .She (Resident #7) felt violated and that her privacy had been invaded. When asked about the reports and the facility's abuse policy, the LSW stated during an interview on 12/18/19 from 8:55 AM to 10:15 AM, the incidents were viewed as grievances and not allegations of potential abuse, neglect, or misappropriation of funds. When asked, the Administrator stated during an interview on 12/18/19 from 8:55 AM to 10:15 AM, the incident was not reported to the State Survey Agency. The facility failed to ensure allegations of abuse, neglect, and misappropriation of resident property were reported to the State Survey Agency.

Based on policy review, review of grievance reports, and staff interview, it was determined the facility failed to ensure allegations of abuse, neglect, and misappropriation of resident property were thoroughly investigated, and corrective action was taken to prevent reoccurrence for 5 of 5 residents (Residents #2, #3, #4, #7, and #8) whose grievance reports were reviewed. This resulted in the potential for residents to be subjected to ongoing abuse, neglect, and misappropriation of resident property. Findings include: The facility's Abuse policy, updated 4/2019, stated It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation .All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee .The investigation, and the results of the investigation, will be documented. The policy included the following definitions: - Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in the definition of abuse, means the individual must have acted deliberately . - Mistreatment: inappropriate treatment or exploitation of a resident. - Misappropriation of resident property: the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongings or money without the resident's consent. - Neglect: the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. - Verbal Abuse: includes the use of oral written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representatives, or within their hearing distance, regardless of their age, ability to comprehend, or disability. The policy also stated investigations would include the following an interview with the person(s) reporting the incident; an interview with the resident(s); interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate; a review of the resident's medical records; an interview with staff members (on all shifts) who may have information regarding the alleged incident; interviews with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident; an interview with staff members (on all shifts) having contact with the accused employee; and a review of all circumstances surrounding the incident. The facility's Grievance Reports, dated 8/28/19 to 12/2/19, were reviewed and included allegations of abuse, neglect, and misappropriation of funds. When asked about the reports and the facility's abuse policy, the LSW stated during an interview on 12/18/19 from 8:55 AM to 10:15 AM, the incidents were viewed as grievances and not allegations of potential abuse, neglect, mistreatment, or misappropriation of funds. The facility's Grievance Reports did not include documentation incidents were thoroughly investigated, and corrective action taken to prevent reoccurrence, as follows: a. A Grievance Report, dated 8/28/19 at 4:45 PM, stated Resident #4 was .visibly upset .feeling very scared because she could not breath. She stated she was poorly positioned and her air was being cut off .(CNA #9) came in and repositioned her .She noted nurse, (LN #1) had been in the room as well, but was in a hurry. She did not seem to understand how frightened and upset (Resident #4) was. Resident #4 told her she couldn't breathe. (LN #1) checked the oxygen and said it was working fine. She didn't understand that it was (Resident #4's) position that was restricting her breathing. The LSW reported to nurse (LN #1) and she requested (CNA #9) and another CNA go back to reposition (Resident #4) again. The report did not include documentation of staff statements or information related to the employee who originally positioned Resident #4. The report also did not include documentation corrective action was taken to prevent reoccurrence. When asked who originally positioned Resident #4, the DNS stated during an interview on 12/18/19 from 8:55 AM to 10:15 AM, they did not know. The Administrator, who was present, stated the facility did not obtain staff statements and no corrective action was taken other than suggesting physical therapy work with Resident #4. b. A Grievance Report, dated 9/12/19, stated Resident #3 .saw (CNA #8) & resident 11B (sic). She believes that there was inappropriate sexual activity going on between them .(Resident #3) reports seeing some of the young, pretty CNAs flirting with resident (sic) 23B. She says they sit in his lap, hug and kiss him . The report did not include documentation of additional resident interviews and staff statements, or information related to the corrective action taken to prevent reoccurrence. When asked, the Administrator stated during an interview on 12/18/19 from 8:55 AM to 10:15 AM, the facility did not obtain resident interviews and staff statement, and there was no documentation corrective action was taken to prevent reoccurrence. c. A Grievance Report, dated 10/1/19, stated Resident #8 stated About 3 weeks ago, I noticed that I had $300 missing out of my room .I reported it to (the Administrator). I did not file a police report because I thought I knew who was doing it. I thought it was a guy that visits residents (sic) in 21. This time .$100 was taken from my bedside table .I want to file a police report. (The Administrator) said he would call them for me. The report did not include additional resident interviews, statements from staff including housekeeping and laundry staff, evidence of a room search, or corrective action taken to prevent reoccurrence. When asked, the Administrator stated during an interview on 12/18/19 from 8:55 AM to 10:15 AM, he talked with other staff including housekeeping and laundry staff, but it was not documented. The Administrator stated a room search was conducted but it was not documented. The Administrator stated no additional residents were interviewed, and no corrective action was taken to prevent reoccurrence other than talking to Resident #8 about keeping his money in a lock box. d. A Grievance Report, dated 10/25/19, stated on 10/24/19 during the evening shift, RN #3 went into Resident #3's room with Resident #3's medication. The report stated My drawer was open and she saw my white box with [MEDICATION NAME] gel. She said I couldn't keep it. I told her that (the DNS) said I could keep it in my drawer. I was also told I could keep my prescription shampoo. (RN #3) threw the box back into my drawer and then slammed my pills onto my bedside table. Some of the pills bounced off the table onto the floor. She turned and left the room .I don't want to deal with (RN #3). She is just nasty . The report stated the Administrator talked with Resident #3's roommate who witnessed the event and verified the incident and RN #3 was educated about her approach with residents. The report did not include documentation of additional resident interviews and staff statements, or information related to the corrective action taken to prevent reoccurrence. When asked, DNS stated during an interview on 12/18/19 from 8:55 AM to 10:15 AM, only the nurse (RN #3) was interviewed. The Administrator, who was present, stated no resident interviews or additional corrective action was taken to prevent reoccurrence. e. A Grievance Report, dated 11/26/19, stated Resident #2 had $40.00 in her pants pocket and suspected CNA #3 had taken it. The report stated money not found. Resident has been reimbursed by facility. Investigation completed + staff interviewed (CNA #3 and CNA #10). The report did not include statements from CNA #3 and CNA #10, additional resident interviews, additional staff statements, or statements from housekeeping staff. There was no documentation a room search was conducted. There was no documentation corrective action was taken to prevent reoccurrence. When asked, the Administrator stated during an interview on 12/18/19 from 8:55 AM to 10:15 AM, no other residents were interviewed. The Administrator stated a room search was conducted but it was not documented, staff and housekeeping were interviewed but it was not documented, and only Resident #2 was educated about securing her money in a lock box. f. A Grievance Report, dated 11/26/19, stated Resident #2 reported (LPN #2) has been nasty to every (sic) since I came here .She said she was mad because I rang the bell (call light) all the time. The report stated She (LPN #2) has been counseled to work on customer service. She realized she needs to improve + will work on it. The report did not include a statement from LPN #2, additional resident interviews, or additional staff statements. There was no documentation of additional corrective action to prevent reoccurrence. LPN #2's personnel record was reviewed and did not include documentation she was counseled. When asked, the DNS stated during an interview on 12/18/19 from 8:55 AM to 10:15 AM, LPN #2 was not interviewed and a statement from her was not obtained. The Administrator, who was present, stated the facility did not obtain additional resident interviews and staff statements, and there was no documentation corrective action was taken to prevent reoccurrence. g. A Grievance Report, dated 11/18/19, stated Resident #2 reported They went to move her up in bed and used her arms rather than (sic) turn sheet .Resident with some discomfort to her right shoulder .Then she went on to say that (CNA #7) wasn't friendly and threw her gloves . The report documented 5 additional residents were interviewed and Resident #9 stated .new gal is a bit rough . and Resident #3 .says tall female aid is rough. She needs some skills. She does not want her to bathe her. The report did not include a statement from CNA #7, or documentation Resident #3's and Resident #9's concerns were addressed. There was no documentation corrective action was taken to prevent reoccurrence. When asked, the DNS stated during an interview on 12/18/19 from 8:55 AM to 10:15 AM, she talked with CNA #7 but a statement from CNA #7 was not obtained. The Administrator, who was present, stated Resident #3 and Resident #9's concerns were not addressed, and there was no documented evidence of corrective action taken to prevent reoccurrence. h. A Grievance Report, dated 12/2/19, stated Resident #7 .saw an employee coming out of her room with some of her special diabetic lotions given to her by her daughter .The unidentified employee stated she was instructed to go through residents' rooms and remove excess toiletries .She (Resident #7) felt violated and that her privacy had been invaded. The report did not include additional resident interviews, or additional staff statements including housekeeping, dietary and laundry staff. There was no documentation additional corrective action was taken to prevent reoccurrence. When asked about the unidentified employee, the Administrator stated during an interview on 12/18/19 from 8:55 AM to 10:15 AM, they were not able to identify the person. The Administrator stated no other residents were interviewed, and dietary, laundry, and additional staff statements were not obtained. The Administrator stated housekeeping staff were interviewed but it was not documented, and no corrective action was taken to prevent reoccurrence. The facility failed to ensure allegations of abuse, neglect, misappropriation of resident property, and exploitation were thoroughly investigated, and corrective action was taken to prevent reoccurrence.

Based on policy review, record review, resident interview, and staff interview, it was determined the facility failed to ensure each resident had the right to exercise his or her rights as a resident of the facility and as a citizen of the United States for 1 of 9 residents (Resident #3) whose records were reviewed. This resulted in the potential for psychosocial harm when a resident was denied the envelope from a personal letter which was addressed to the resident. Findings include: The facility's Rights policy, dated 5/2017, stated residents had a right To be encouraged and assisted throughout his or her stay in the Center to exercise these Resident Rights as well as those which Residents are entitled as a U.S. (United States) citizen. Resident #3's record documented as of 10/7/19, her BIMS score was 13 (indicating little to no cognitive impairment). Resident #3 was interviewed on 12/16/19 from 1:00 PM to 1:42 PM. During the interview, Resident #3 stated she received a letter from her estranged daughter. Resident #3 stated she requested the LSW read the letter to her as she was shaking. Resident #3 stated the LSW left the letter with her but took the envelope. Resident #3 stated she asked for the envelope, which contained her daughter's address, and the LSW refused to give it to her. When asked, the LSW stated during an interview on 12/16/19 from 4:20 PM to 4:30 PM, Resident #3's daughter called and emailed the LSW and requested her address not be given to Resident #3. The LSW stated Resident #3 did ask for the envelope and the LSW told Resident #3 she could not have it due to the daughter's request. The facility failed to ensure Resident #3 had the right to exercise her rights as a resident of the facility and as a citizen of the United States.

Based on policy review, review of grievance reports, and staff interview, it was determined the facility failed to ensure residents were free from abuse, neglect, and misappropriation of resident property for 2 of 5 residents (Residents #2 and #3) whose grievance reports were reviewed. This resulted in the potential for residents to be subjected to ongoing abuse, neglect, and misappropriation of resident property. Findings include: The facility's Abuse policy, updated 4/2019, stated It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation .All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee .The investigation, and the results of the investigation, will be documented. The policy included the following definitions: - Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in the definition of abuse, means the individual must have acted deliberately . - Mistreatment: inappropriate treatment or exploitation of a resident. - Misappropriation of resident property: the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongings or money without the resident's consent. - Neglect: the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. - Verbal Abuse: includes the use of oral written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representatives, or within their hearing distance, regardless of their age, ability to comprehend, or disability. The policy also documented investigations would include the following an interview with the person(s) reporting the incident; an interview with the resident(s); interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate; a review of the resident's medical records; an interview with staff members (on all shifts) who may have information regarding the alleged incident; interviews with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident; an interview with staff members (on all shifts) having contact with the accused employee; and a review of all circumstances surrounding the incident. The facility's Grievance Reports, dated 8/28/19 to 12/2/19, included allegations of abuse and neglect, as follows: a. A Grievance Report, dated 9/12/19, stated Resident #3 .saw (CNA #8) & resident 11B (sic). She believes that there was inappropriate sexual activity going on between them .(Resident #3) reports seeing some of the young, pretty CNAs flirting with resident (sic) 23B. She says they sit in his lap, hug and kiss him . b. A Grievance Report, dated 10/25/19, stated on 10/24/19 during the evening shift, RN #3 went into Resident #3's room with Resident #3's medication. The report stated My drawer was open, and she saw my white box with [MEDICATION NAME] gel. She said I couldn't keep it. I told her that (the DNS) said I could keep it in my drawer. I was also told I could keep my prescription shampoo. (RN #3) threw the box back into my drawer and then slammed my pills onto my bedside table. Some of the pills bounced off the table onto the floor. She turned and left the room .I don't want to deal with (RN #3). She is just nasty . The report stated the Administrator talked with Resident #3's roommate who witnessed the event and verified the incident. c. A Grievance Report, dated 11/18/19, stated Resident #2 reported They went to move her up in bed and used her arms rather than (sic) turn sheet .Resident with some discomfort to her right shoulder .Then she went on to say that (CNA #7) wasn't friendly and threw her gloves . The report documented 5 additional residents were interviewed and Resident #9 stated .new gal is a bit rough . and Resident #3 .says tall female aid is rough. She needs some skills. She does not want her to bathe her. d. A Grievance Report, dated 11/26/19, stated Resident #2 reported (LPN #2) has been nasty to every (sic) since I came here .She said she was mad because I rang the bell (call light) all the time. When asked about the reports and the facility's abuse policy, the LSW stated during an interview on 12/18/19 from 8:55 AM to 10:15 AM, the incidents were viewed as grievances and not allegations of potential abuse or neglect. The facility failed to ensure residents were free from potential abuse and neglect.

Based on observation, record review, policy review, resident interview, and staff interview, it was determined the facility failed to implement comprehensive resident-centered care plans related to oral/denture care. This was true for 1 of 6 residents (Resident #2) whose care plans were reviewed. This resulted in the potential for a resident to experience adverse outcomes if they did not receive adequate oral care. Findings include: The facility's policy, titled Oral Hygiene - Brushing Teeth and Care of Dentures, revised 5/2007, stated If the resident has dentures, ask resident to remove them for cleaning .Put dentures in denture cup and take to appropriate area for cleaning .Clean with tap water and denture cleaning product. Brush up and down rather than across dentures. Check for broken pieces .Check the resident's mouth for unusual sores. Report any unusual observations to the charge nurse .Chart oral care and appropriate observations. Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #2's care plan, dated 10/4/19, documented she had upper and lower dentures and staff were to assist her to care for them. On 12/16/19 at 4:11 PM, Resident #2's dentures were observed on her bedside table, not in a cup. The upper dentures had dark brown speckles embedded on the palate. The teeth on the dentures were dull (not shiny) and had many green food particles on and between the teeth. When asked by the surveyor how often the facility cleaned her dentures, Resident #2 said she did not know, but sometimes they put them in a cup with liquid, but she didn't know if it was water or something else. She did not recall if anyone brushed them. Resident #2 said she had a sore area on her lower left gum and it was really bothering her. She said she thought it was because her dentures did not fit right. Resident #2 did not recall anyone asking to look in her mouth or offering her mouthwash or other oral care. Resident #2's record did not include documentation specific to her oral care, how often it was offered, or documentation of oral inspection. On 12/17/19 at 7:10 AM, when asked about the sore area on Resident #2's lower left gum, RN #1, who was caring for Resident #2, stated, this is the first I've heard about it. When asked how often residents received oral care, RN #1 stated the CNAs provided oral care and she believed it was offered once a shift. During an interview on 12/19/19 at 10:09 [NAME]M., the DNS said she expected residents to receive oral care at a minimum of twice a day, in the morning, in the evening, and as needed. The DNS stated residents' records did not have an area under the personal care section specific to document oral care. The facility failed to ensure Resident #2 received oral care in accordance with their policy.

Based on record review, staff interview, and provider interview, it was determined the facility failed to ensure outside providers received current medical information for residents who went outside the facility for medical appointments. This was true for 1 of 6 residents (Resident #2) whose records were reviewed. This resulted in the potential for a resident to experience adverse outcomes if they did not receive appropriate medication and treatment due to lack of information when the resident met with their physician. Findings include: The official journal website for the American Nurses Association, American Nurse Today, accessed on 12/19/19, included an article about transport teams and patient handoff reports, dated 10/2/19. The article documented: Transport teams understand that written handoffs won't (sic) always be available; however, some forms (for example, medical necessity and demographic forms) are required for patient transport. Verbal report at a minimum (preferably accompanied by printed or electronic written documentation) should include: * name * gender * age * code status * chief complaint * diagnosis * pertinent medical history * current illness/injury history * pertinent laboratory and imaging results and significant laboratory trends * allergies [REDACTED].* medications and interventions administered within the last 24 hours and patient response * treatment plan * reason for transfer * likelihood of significant negative or positive change in patient condition Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A progress note from the a wound center, dated 12/9/19, documented Resident #2 arrived by wheelchair for an appointment. Resident #2's record did not include documentation a verbal report prior to her transfer to the wound clinic was given or documentation paperwork was sent with her for her provider to review. During a phone interview on 12/17/19 at 9:30 AM, the CMA from Resident #2's wound clinic stated, Resident #2 arrived for her appointment on 12/9/19 without paperwork about her current medical status, and the clinic did not receive a verbal report from the facility. She stated this made it difficult to provide needed care and treatment for [REDACTED]. During an interview with the DNS on 12/18/19 at 10:09 AM, she stated she expected the nurse or medical records personnel from the facility to print out the medication sheet, vital signs, daily weights, blood sugar reports, and progress notes and transport those records with the resident to outside clinic appointments.

Based on record review, resident interview, staff interview, and provider interview, it was determined the facility failed to ensure each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This was true for 1 of 6 residents (Resident #2) whose records were reviewed. This resulted in the potential for a resident to experience adverse outcomes if they did not receive oxygen as ordered. Findings include: Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #2's physician's orders [REDACTED]. Resident #2's care plan, dated 10/7/19, documented she was to be provided with oxygen as ordered. A progress note from the a wound center, dated 12/9/19, documented Resident #2 arrived by wheelchair for an appointment. The note did not include documentation that she had her oxygen. During an interview on 12/16/19 at 2:12 PM, CNA #1 said she oversaw medical records and resident transport for the facility. CNA #1 said when residents were taken to appointments outside of the facility, she brought needed equipment with residents to keep them safe, such as wheelchairs, walkers, and oxygen. During an interview on 12/16/19 at 4:11 PM, Resident #2 stated she went to see her doctor at the clinic last Monday (12/9/19). Resident #2 said CNA #1 drove her to the appointment and she arrived without her oxygen. Resident #2 said when she went into the building, it was discovered she did not have her oxygen. She stated CNA #1 went outside to the vehicle and brought back a small oxygen tank that was used for emergencies. During a phone interview on 12/17/19 at 9:30 AM, the CMA from the wound clinic stated Resident #2 arrived for her appointment on 12/9/19 without oxygen or a nasal cannula to connect to oxygen. The CMA stated CNA #1, who accompanied Resident #2 to her appointment, went outside to the vehicle Resident #2 was transported in and brought a small emergency oxygen canister and cannula for Resident #2. On 12/18/19 at 10:09 AM, the DNS said when residents were taken to outside appointments, she expected residents were assessed for their physical function and all needed equipment was transported to the appointment with them such us a wheelchair, walker, and oxygen. Resident #2 did not have her oxygen on as ordered by the physician during her transport to the wound clinic.

Based on observation, record review, policy review, and staff interviews, it was determined the facility failed to ensure neurological assessments were performed after unwitnessed falls and/or incidents involving a potential head injury, and medications were administered consistent with physician orders. This was true for 5 of 5 residents (#5, #19, #21, #22, and #27) reviewed for falls, and 1 of 8 residents (Resident #7) reviewed for medication administration. These failures created the potential for harm should residents experience undetected changes in neurological status and adverse effects from medications that were administered contrary to physician orders. Findings include: The facility's policy for Neurological Evaluation, revised (MONTH) 2007, documented the following: * All incidents involving head trauma result in a comprehensive neurological assessment for a minimum of 72 hours. * A neurological assessment flowsheet was used for all residents who sustained head trauma due to falls or other incidents. * Any resident who had an injury involving the head or an observed fall required neurological checks and vital signs at least every 8 hours for 24 hours or per specific facility policy or physician's orders [REDACTED].>* Comprehensive neurological assessments were done every 15 minutes times 4 (one hour), every 30 minutes times 4 (two hours), every hour times 4 (four hours), and every shift times 72 hours. This policy did not include consistent instructions to staff when to conduct a neurological assessment, how frequently a resident should be assessed, and the duration of time for the neurological assessments. Neurological assessments were not completed as follows: a. Resident #5 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 4/26/19, documented Resident #5 was severely cognitively impaired and required extensive assistance from two staff members for bed mobility and transfers. - An Incident and Accident Report, dated 7/8/19 at 3:13 PM, documented Resident #5 was found lying on the floor to the right of her door. The report stated Resident #5 had no injuries from the fall. There was no documentation in Resident #5's record neurological assessments were completed after the fall. - An Incident and Accident Report, dated 7/12/19 at 5:29 PM, documented Resident #5 experienced an unwitnessed fall out of bed and was found on the floor on a mat next to her bed. The report stated Resident #5 had no injuries from the fall. There was no documentation in Resident #5's record neurological assessments were completed after the fall. - An Incident and Accident Report, dated 7/18/19 at 6:05 AM, documented Resident #5 experienced an unwitnessed fall out of bed and was found on the floor on a mat next to her bed. The report stated Resident #5 had no injuries from the fall. There was no documentation in Resident #5's record neurological assessments were completed after the fall. - An Incident and Accident Report, dated 7/22/19 at 10:46 AM, documented Resident #5 experienced an unwitnessed fall out of bed and was found on the floor on mat next to the bed. There was no documentation in Resident #5's record neurological assessments were completed after the fall. On 7/24/19 at 9:25 AM, the DNS stated Resident #5's record did not include neurological assessments for the falls on 7/8/19, 7/12/19, 7/18/19, or 7/22/19. b. Resident #21 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #21's quarterly MDS assessment, dated 6/2019, documented he was severely cognitively impaired and required extensive assistance of two persons with bed mobility and transfers. Resident #21 had two falls which resulted in injuries to his head and neurological assessments were not completed as follows: - An Incident and Accident Report, dated 1/19/19 at 6:00 AM, documented he had an unwitnessed fall with a hematoma (swelling of clotted blood in the tissue) and two abrasions to his forehead. There was no documentation in Resident #21's record neurological assessments were completed after the fall. - An Incident and Accident Report, dated 7/17/19 at 9:37 PM, documented Resident #21 bumped his right temple area on the wall in the shower room when he stood up from his wheelchair and attempted to bite a CNA as she attempted to transfer him to the toilet. There was no documentation in Resident #21's record neurological assessments were completed after he bumped his head. On 7/24/19 at 10:55 AM, the DNS said neurological assessments should have been done after Resident #21's falls on 1/21/19 and 7/17/19. The DNS said if he hit his head there should have been further assessment. c. Resident #19 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #19's quarterly MDS assessment, dated 6/11/19, documented he was severely cognitively impaired and required extensive assistance of two persons with bed mobility and transfers. An Incident and Accident Report, dated 7/9/19 at 3:50 PM, documented Resident #19 was found on the floor next to his bed. There was no documentation in Resident #19's record neurological assessments were completed after he fell . On 7/24/19 at 10:55 AM, the DNS said neurological assessments should be done if it was unsure whether the resident hit their head, there were visible signs and symptoms they hit their head, or the resident said they hit their head. d. Resident #27 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #27's quarterly MDS assessment, dated 7/1/19, documented he was cognitively intact and required physical assistance from one person for bed mobility and transfers. An Incident and Accident Report, dated 5/19/19 at 5:55 AM, documented Resident #27 was found lying on his left side between the wall and his bed. The report stated Resident #27 had a hematoma on the left of his forehead. The LPN documented neurological assessments were initiated and were within normal limits. There was no documentation in Resident #27's record neurological assessments were completed after he fell . On 7/24/19 at 5:30 PM, the DNS said she could not find neurological assessments in Resident #27's record after his fall on 5/19/19. e. Resident #22 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A readmission MDS assessment, dated 6/21/19, documented Resident #22 was severely cognitively impaired and required extensive assistance with two staff members for bed mobility and transfers. An Incident and Accident Report, dated 7/11/19 at 3:15 AM, documented Resident #22 experienced an unwitnessed fall out of bed. The report stated Resident #22 had no injuries from the fall. There was no documentation in Resident #22's record neurological assessments were completed after he fell . On 7/25/19 at 8:40 AM, the DNS stated Resident #22's record did not include neurological assessments for his unwitnessed fall on 7/11/19. The DNS stated Resident #22 had an unwitnessed fall and neurological assessments should have been implemented. 2. The facility's policy for the Six Rights of Medication Administration, revised (MONTH) 2007, documented one of the Six Rights included the right time-Medications are administered within prescribed time frames. Resident #7 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #7's physician orders [REDACTED]. On 7/24/19 at 4:47 PM, RN #1 administered the Humalog to Resident #7 in her left upper abdomen. No meal was served at that time, and dinner was not scheduled to be served until 5:30 PM (almost 45 minutes later). RN #1 said Resident #7 wanted the Humalog before dinner or right at dinner because she received another 28 units at bedtime, and she did not want them given too close together or her blood sugar could get too low. RN #1 said she did not administer the Humalog after dinner as ordered by Resident #7's physician. On 7/24/19 at 5:30 PM, the DNS said, the Humalog should be given to Resident #7 after dinner, and if Resident #7 wanted to receive the medication earlier due to the reasons described above, her physician should have been contacted. 5. Resident #5 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. The quarterly MDS assessment, dated 4/26/19, documented Resident #5 was severely cognitively impaired and required extensive assistance from two staff member for bed mobility and transfers. a. An Incident and Accident Report, dated 7/8/19 at 3:13 PM, documented Resident #5 was found lying on the floor on her right side in her room next to bed. Resident #5 had no injuries from the fall. Neurological assessments following Resident #5's unwitnessed fall were not found in her record. b. An Incident and Accident Report, dated 7/12/19 at 5:29 PM, documented Resident #5 experienced an unwitnessed fall out of bed. Resident #5 had no injuries from the fall. Neurological assessments following Resident #5's unwitnessed fall were not found in her record. c. An Incident and Accident Report, dated 7/18/19 at 6:05 AM, documented Resident #5 experienced an unwitnessed fall out of bed. Resident #5 had no injuries from the fall. Neurological assessments following Resident #5's unwitnessed fall were not found in her record. d. An Incident and Accident Report, dated 7/22/19 at 10:46 AM, documented Resident #5 experienced an unwitnessed fall out of bed and sustained a bruise and skin tear to the outer part of her right eyebrow. A neurological assessment was documented on the Incident and Accident Report. Neurological assessments following Resident #5's unwitnessed fall were not found in her record. On 7/24/19 at 9:25 AM, the DNS stated Resident #5's record did not include neurological assessments for the falls on 7/8/19, 7/12/19, 7/18/19, or 7/22/19. The DNS stated she spoke to the LPN regarding Resident #5's unwitnessed fall and she did initiate neurological checks, but she did not implement them per the facility's policy on a neurological assessment flow sheet. 6. Resident #22 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A readmission MDS assessment, dated 6/21/19, documented Resident #22 was severely cognitively impaired and required extensive assistance with two staff members for bed mobility and transfers. An Incident and Accident Report, dated 7/11/19 at 3:15 AM, documented Resident #22 experienced an unwitnessed fall out of bed. Resident #22 had no injuries from the fall. Neurological assessments following Resident #22's unwitnessed fall were not found in his record. On 7/25/19 at 8:40 AM, the DNS stated Resident #22's record did not include neurological assessments for his unwitnessed fall on 7/11/19. The DNS stated Resident #22 had an unwitnessed fall and neurological assessments should have been implemented.

Based on record review and staff interview, it was determined the facility failed to ensure the resident or the resident's representative received information and assistance to exercise their right to formulate an Advance Directive. This was true for 1 of 4 residents (Resident #15) reviewed for an Advance Directive. The deficient practice created the potential for harm should resident's wishes regarding end of life or emergent care not be honored when they were incapacitated. Findings include: Resident #15 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #15's record did not contain an Advance Directive or documentation the facility provided Resident #15 or Resident #15's representative information on an Advance Directive, and offered assistance to develop an Advance Directive if desired. On 7/23/19 at 3:48 PM, the Admission Coordinator reviewed Resident #15's record and said it did not include an Advance Directive. The Admission Coordinator said Resident #15's record did not include documentation the facility discussed with Resident #15 or Resident #15's representative Advance Directives or assistance to complete an Advance Directive.

Based on staff interview and record review, it was determined the facility failed to ensure a resident's representative was notified in a timely manner of a resident's significant change in condition which required hospitalization . This was true for 1 of 4 residents (Resident #30) reviewed for notification of changes. This placed the resident at risk of inappropriate care and treatment due to lack of advocacy and involvement by their representative. Findings include: Resident #30 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A Nurse's Progress Note, dated 5/20/19 at 5:24 PM, documented Resident #30 was attempting to exit the building. The facility staff were attempting to redirect him and Resident #30 became physically and verbally abusive to a staff member. The police, Emergency Medical Services (EMS), and the physician were notified of the behaviors and Resident #30 was sent to the ER (emergency room ) for an evaluation. Resident #30 was admitted to the hospital. A Nurse's Progress Note, dated 5/21/19 at 4:50 PM, documented the LSW notified Resident #30's spouse he was admitted to the hospital for the incident that happened on 5/20/19. On 7/25/19 at 3:28 PM, the DNS was unable to provide additional documentation Resident #30's spouse was notified he was sent to theER on [DATE]. The DNS stated the facility should have notified Resident #30's spouse he was sent to the hospital the day of the incident on 5/20/19. On 7/25/19 at 3:35 PM, the LSW stated she did not notify Resident #30's spouse he was sent to the hospital until 5/21/19. The LSW stated the facility staff thought his spouse was in the facility visiting when he was sent to the ER. On 7/25/19 at 3:41 PM, the Administrator stated Resident #30 was verbally upset towards his spouse on 5/20/19 and she left the facility. The Administrator stated the physician was notified of Resident #30's behavior, and per the physician's orders [REDACTED]. The Administrator stated Resident #30's spouse had left the facility and was not aware he was sent to the hospital.

Based on record review and staff interview, it was determined the facility failed to ensure a resident's code status was documented on their baseline care plan. This was true for 1 of 2 residents (Resident #130) reviewed for baseline care plans. This failure created the potential for harm should a residents' wishes not be followed regarding their code status due to lack of information on the baseline care plan. Findings include: Resident #130 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #130's physician orders [REDACTED]. Resident #130's Preferred Intensity of Care form documented she was a DNR, and it was signed by her representative on 7/16/19. Resident #130's Initial Care Plan, dated 7/16/19, did not include documentation regarding her code status. On 7/25/19 at 2:50 PM, the DNS said Resident #130's code status was not documented on the baseline care plan. The DNS said the facility typically documented the code status on the initial care plan within 48 hours.

Based on observation, record review, policy review, and resident, resident family member, and staff interview, it was determined the facility failed to ensure care plans were revised and updated as care needs changed. This was true for 1 of 13 residents (Resident #13) whose care plans were reviewed. This failure created the potential for harm if cares and/or services were provided based on inaccurate information on the care plan. Findings include: The facility's policy for Comprehensive Person-Centered Care Planning, revised (MONTH) (YEAR), documented each resident's care plan was reviewed and/or revised by the Interdisciplinary Team (IDT) after each assessment. Resident #13 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #13's care plan documented she was not to be resuscitated, Do Not Resuscitate (DNR), and to provide comfort measures and limited interventions, initiated on [DATE]. The care plan also documented Resident #13 wanted cardiorespiratory resuscitation (CPR) and was a Full Code, initiated one day later on [DATE]. Resident #13's Care Plan Conference Summary, dated [DATE], documented she changed her code status from DNR to Full Code. Resident #13's record included a physician order, dated [DATE], for Full Code and her Preferred Intensity of Care form documented she wished for all efforts at revival in the event of sudden death (Full Code). On [DATE] at 3:35 PM, LPN #1 said Resident #13's code status was no longer DNR, she recently went to the doctor and it was changed to Full Code. On [DATE] at 4:11 PM, the LSW said Resident #13 recently had a care conference and she updated her code status. The LSW said the information on the care plan that documented DNR was an error. On [DATE] at 4:26 PM, the DNS said Resident #13 recently had a care conference and she changed her code status to Full Code. The DNS said Resident #13's care plan included previous information that was not correct regarding her code status.

Based on record review, policy review, and resident and staff interview, it was determined the facility failed to provide showers and communication assistance as needed. This was true for 2 of 12 residents (#13 and #18) whose activities of daily living were reviewed. This failure placed the residents at risk of psychosocial distress related to embarrassment and/or isolation from not receiving showers and not being able to communicate. Findings include: 1. The facility's policy for Restorative Care, revised 11/2017, documented objectives for providing direct nursing care services that maintained optimum physical and mental health for the resident and meet all his medical treatment needs, and Participate in the retraining of the resident in self-care activities. Residents would be evaluated on their ability to carry out activities of daily living (ADLs), including the ability to understand speech and talk. Resident #13 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #13's quarterly MDS assessment, dated 5/27/19, documented she had unclear speech and was rarely/never understood, she usually understood others, and she was severely cognitively impaired. Resident #13's care plan documented she had a computerized communication device, a Dynavox, and communication cards and staff were to use these communication tools as recommended by Speech Therapy (ST), initiated on 1/24/19. An ST discharge summary, signed by the Speech Therapist on 1/22/19, documented Resident #13 required daily assistance and encouragement from staff to use her communication device, the Dynavox. The discharge summary stated Resident #13 wanted and was able to use the communication device but did not have the staff support or knowledge. The summary also stated staff needed continued encouragement and familiarization with the ST tools and this should be done with the Restorative Program. The ST discharge summary stated a communication program was established with the restorative aide. A progress note, dated 3/27/19 at 10:47 AM, documented Will discontinue program for now as Resident (sic) is not showing improvement .doesn't retain how to use Dynavox, one worded questions work best at this time. She tends to get overwhelmed which seems to upset her. A Care Plan Conference summary, dated 6/18/19, documented Resident #13 had a Dynavox for communication and communication was a barrier. There was no further documentation in the summary about Resident #13's barriers to communication or how it was going to be addressed. A Care Conference note, dated 6/18/19 at 4:58 PM, stated Resident #13 continued to experience frustration regarding not being able to communicate, and she attempted to write her responses but was unsuccessful. On 7/23/19 at 3:52 PM, Resident #13's family member said he never saw Resident #13 use the Dynavox or staff attempt to use it with her. When asked if she liked the Dynavox, Resident #13 shook her head side-to-side indicating no. On 7/23/19 at 4:01 PM, a Dynavox was observed on the counter in Resident #13's room and it was plugged into the wall outlet. CNA #1 said it was hard to communicate with Resident #13 and her yes/no questions were confused. CNA #1 said Resident #13 had a communication device, but she never saw it being used. CNA #1 said she did not know how to use the communication device. On 7/23/19 at 4:46 PM, LPN #2 said Resident #13 had pictures on her wall (used as communication aids) but she did not use them. LPN #2 said she had never seen Resident #13 use the Dynavox and staff did not touch it. LPN #2 said she thought Resident #13 used to be on a Restorative Program. On 7/24/19 at 8:52 AM, CNA #2 said the Speech Therapist previously trained her on Resident #13's Dynavox. CNA #2 said Resident #13 did not like to use the Dynavox very much and she became a little overwhelmed with it. CNA #2 said the last time Resident #13 used the Dynavox was about 2 weeks ago, and it was not part of her Restorative Program. CNA #2 said other staff knew Resident #13 did not like to use the Dynavox, and she did not know if it was discontinued. CNA #2 said the speech therapist was informed Resident #13 did not like to use the Dynavox, and she said to use whatever Resident #13 was most comfortable with. On 7/24/19 at 10:47 AM, the DNS said the staff received training to help Resident #13 use the Dynavox. The DNS said it was supposed to be an option for Resident #13 to use the Dynavox, but staff had to initiate it. The DNS said she had not observed Resident #13 use the Dynavox. On 7/25/19 at 9:44 AM, the Speech Therapist said she was not sure if Resident #13 still used the Dynavox, staff would have to initiate it, and she had not observed it being used recently. The Speech Therapist said Resident #13 did not have a lot of therapy because there was no payment method for that. The Speech Therapist said she had not followed up with Resident #13 and did not know if she was still on a Restorative Program. 2. Resident #18 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #18's care plan documented Resident #18 required supervision/set-up with the assistance of 1 staff member for showering. Resident #18's Care Plan Conference summary, dated 7/2/19, documented Resident #18 preferred evening showers. On 7/24/19 at 3:30 PM, Resident #18 said she did not remember the last time she had a shower. The daily shower schedule forms for (MONTH) 2019 documented Resident #18 received showers on 6/30/19, 7/17/19, and 7/21/19. The forms for (MONTH) 2019 documented Resident #18 did not receive a shower for 17 days between 6/30/19 and 7/17/19. The bathing schedule in the electronic record for (MONTH) 2019 and (MONTH) 2019 documented Resident #18 did not receive a shower for 21 days between 6/30/19 and 7/21/19. The facility's tool to track the residents' showering schedule, and completion of showers, was a paper form that was posted. It identified the date and shift, which residents were to get showers that shift, and which CNA was assigned to the residents. The shower schedule, dated 7/10/19, initiated by the DNS, documented Resident #18's showers were to be provided every Sunday and Wednesday evening. Those residents with a change in their scheduled showers had the day/shift identifiers circled, if they refused or did not receive a shower that day. Resident #18's day/shift identifier was not circled on the days and shifts she did not receive a schedule. On 7/24/19 at 4:03 PM, LPN #1 said staff knew to shower a resident by reading the daily shower schedule form that was posted. LPN #1 said staff procedure was to offer the resident assistance with a shower 3 times during the scheduled shift, and if the resident refused 3 times they wrote the resident's name on the next day's shower schedule form. On 7/24/19 at 4:03 PM, the DNS said on 7/10/19 she implemented the policy of re-scheduling a resident on the next day's shower schedule with the date the original shower was offered and refused and this was to be repeated until a shower was provided. The DNS said the electronic record has priority over the paper shower schedule which was posted daily. On 7/24/19 at 4:10 PM, the DNS said she reviewed Resident #18's electronic record and said it documented Resident #18 was provided a shower on 6/30/19, had refused a shower on 7/3/19 and 7/14/19, and her next shower was on 7/21/19. The DNS was unable to provide documentation Resident #18 was provided a shower on 7/17/19. The DNS said Resident #18 did not get a shower for 21 days.

Based on resident and staff interview and record review, it was determined the facility failed to ensure residents received restorative services through the restorative nursing program as needed. This was true for 2 of 2 residents (#9 and #13) reviewed for the restorative nursing program. This failure created the potential for residents to experience a decline in Range of Motion (ROM). Findings include: 1. Resident #9 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 5/13/19, documented Resident #9 was to receive active ROM and walking therapy through the restorative nursing program. Resident #9's care plan, revised on 5/9/19, documented the restorative program was to provide active ROM exercises 5-6 times a week for 15 minutes. Resident #9's care plan, revised 6/26/19, documented the restorative program was also to provide walking assistance 5-6 times a week, and Resident #9 tended to walk better first thing in the morning, typically around 7 AM. Resident #9 received restorative nursing services 4 days a week for the last 3 weeks of (MONTH) 2019, and he received restorative nursing services 2 to 3 days a week in (MONTH) 2019, from 7/1/19 to 7/22/19. A progress note, dated 7/17/19 at 10:06 AM, documented Resident #9 received restorative nursing for active ROM and ambulation, and Resident #9 participated well with active ROM and ambulation, and the plan of care was to be continued. On 7/22/19 at 11:02 AM, Resident #9 said he was waiting to be walked and had not walked since last Wednesday, 7/17/19. The restorative nursing schedule, dated 7/23/19, documented Resident #9 was in the ROM and ambulation program and was to ambulate in the morning. There was no documentation Resident #9 was ambulated by restorative nursing staff on 7/23/19. On 7/24/19 at 9:45 AM, the DNS said times/dates for restorative nursing were recorded under the care plan in the residents' records. Resident #9's record documented Resident #9 received restorative nursing 3-4 days the last three weeks of (MONTH) 2019 and received restorative nursing 2-3 days a week in (MONTH) 2019. On 7/24/19 at 11:13 AM, the MDS Coordinator said the goal was to provide restorative nursing for Resident #9 6-7 days a week and to staff someone who could provide these services on weekends, and without weekend staff the goal was reduced to 5-6 days a week. The MDS coordinator reviewed both electronic record and hard copy documentation and said Resident #9 had not received ROM or restorative nursing rehab since 7/17/19. On 7/24/19 at 11:37 AM, the DNS said the restorative nursing goal for Resident #9 was 5 days a week and weekend coverage on one weekend day with a total of 6 days a week. Resident #9 was not provided restorative nursing therapy the 5-6 days a week as directed in the care plan. 2. Resident #13 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #13's quarterly MDS assessment, dated 5/27/19, documented she was severely cognitively impaired, required extensive assistance of two persons for bed mobility, transfers, dressing, and toileting, and she received restorative program services on 4 of the past 7 days. Resident #13's physician orders [REDACTED]. Resident #13's care plan directed restorative nursing be provided as follows: * Bed mobility 15 minutes, 5-6 times per week, initiated on 5/20/19. * Passive range of motion (ROM) 15 minutes, 5-6 times per week, initiated on 5/20/19. Resident #13's restorative program schedule documented she received restorative services four times a week 6/1/19 to 6/7/19, 6/8/19 to 6/15/19, 6/16/19 to 6/22/19, and 6/23/19 to 6/30/19. She received Restorative Nursing four times a week 7/1/19 to 7/8/19 and 7/9/19 to 7/15/19, and two times between 7/16/19 and 7/22/19. Resident #13 did not receive Restorative Nursing during the week of 7/6/19 to 7/11/19 and 7/18/19 to 7/22/19. On 7/23/19 at 3:52 PM, Resident #13's family member said he had not seen staff provide therapy or exercises to her. On 7/24/19 at 8:52 AM, CNA #2 said Resident #13 was supposed to receive restorative services for ROM and bed mobility every day, Monday through Friday. CNA #2 said she was injured earlier in the month, and another CNA was helping to try to get back on track. CNA #2 said the goal was for Resident #13 to receive restorative services 6 days a week. CNA #2 said Resident #13 missed some restorative nursing services this month, and she only received it four times a week in June. On 7/24/19 at 10:47 AM, the DNS said there were some issues with restorative nursing services since the restorative CNA was injured, and they had trouble getting someone to fill in but it was worked out. The DNS said goal was to have restorative nursing services five to six days a week.

A federal deficiency was cited at F584. Refer to survey PTHG12 for details of this citation.

Based on observation, staff interview, policy review, and record review, it was determined the facility failed to prevent the development of avoidable pressure ulcers. This was true for 2 of 5 (#2 and #6) residents reviewed for pressure ulcers. Resident #2 was harmed when she developed stage III pressure ulcers to her buttocks and heels. Resident #6 was harmed when she developed moisture associated skin damage (MASD) that worsened to a stage III pressure ulcer to her sacrum. Findings include: The facility's Wound Management policy and procedure, dated (MONTH) 2007, documented nursing staff were to complete weekly skin assessments, a wound flow sheet was to be started when a wound was identified, wounds would be measured weekly, and treatments ordered by the physician would be re-evaluated every two weeks if there was no improvement to the wound. 1. Resident #6 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #6's annual MDS assessment, dated 9/11/18, documented she was severely cognitively impaired and required two person assistance with bed mobility and transfers. The MDS assessment documented Resident #6 was at risk for pressure ulcers and had no unhealed pressure ulcers. Resident #6's (MONTH) (YEAR) physician's orders [REDACTED]. A weekly Skin Evaluation report, dated 7/3/18 at 8:13 AM, documented Resident #6 had MASD to her left gluteal fold (a prominent fold that marks the upper limit of the thigh from the lower limit of the buttock) that measured 0.5 x 0.5 x 0 cm with no depth or tunneling. The staff were to continue to apply [MEDICATION NAME] cream to the gluteal fold every shift and as needed. A weekly Skin Ulcer Non-Pressure record, dated 7/11/18 at 4:44 PM, documented Resident #6 developed MASD to right buttock on 7/1/18 that measured 2.0 x 1.5 x 0 cm. The wound was intact and discolored with pink color in the wound bed. The document directed staff to continue to apply barrier cream and apply an air mattress to Resident #6's bed to facilitate healing. A weekly Skin Evaluation report, dated 7/18/18 at 3:12 PM, documented Resident #6 had MASD to the left gluteal fold which measured 0.3 x 0.3 x 0 cm. Resident #6's care plan for potential skin breakdown and MASD to sacrum (low back), revised 7/19/18, documented staff were to apply an air bed/pressure relieving mattress and wheelchair cushion; apply barrier cream after each incontinence episode, document the location of the wound and the progress in wound healing on an ongoing basis, and notify the physician as indicated. A Nurse's Progress Note, dated 8/11/18 at 9:39 PM, documented Resident #6 had an open pressure ulcer on her left buttock and staff were to continued to apply barrier cream until the physician was contacted for new treatment orders. A weekly Skin Evaluation report, dated 8/12/18 at 6:00 AM, documented Resident #6 had MASD to left buttocks with measurements of 0.5 x 0.5 x 0 cm and MASD to her sacrum with measurements of 1 x 0.8 x 0 cm. A dressing was applied and will continue to monitor. Resident #6's clinical record did not include documentation the physician was notified of the development of the pressure ulcer on 8/11/18 and there was not an order for [REDACTED]. A Nurse's Progress Note, dated 8/18/18, documented Resident #6 had two pressure ulcers on her buttocks and educated staff to turn Resident #6 side to side to keep her off of her buttocks. Resident #6's clinical record did not include documentation the physician was notified of the two pressure ulcers to her buttocks. A weekly Skin Evaluation report, dated 8/19/18, documented Resident #6 had an open area to her coccyx (tailbone) and staff continued to apply [MEDICATION NAME] barrier cream for treatment. A weekly Skin Evaluation report, dated 8/26/18, documented Resident #6 had a pressure ulcer to her left buttock with measurements of 0.3 x 0.2 x 0 cm and a stage II pressure ulcer to her sacrum with measurements of 0.5 x 0.2 x 0.1 cm. There was no documentation from 8/11/18 to 8/26/18 the facility notified the physician that Resident #6 had developed a pressure ulcer to her left buttock and a stage II pressure ulcer to her sacrum. The care plan was not revised to direct staff to turn Resident #6 side to side to keep her off of her buttocks. A Nurse's Progress Note, dated 9/4/18 at 3:31 PM, documented Resident #6 had an open area to her sacrum. A Skin Ulcer Non-Pressure Weekly report signed by the wound nurse, dated 9/14/18 at 1:01 PM, documented Resident #6 had MASD to her sacrum with measurements of 1.5 x 0.5 x 0 cm. The report documented Resident #6 was being offloaded (elimination or reduction of pressure) during the day and [MEDICATION NAME] was applied every shift and as needed. The care plan was not revised to direct staff to offload Resident #6 during the day. A weekly Skin Evaluation report, dated 9/17/18 at 11:03 AM, documented Resident #6 had MASD to her sacrum with measurements of 1.0 x 0.5 x 0.1 cm. A weekly Skin Evaluation report, dated 9/24/18 at 11:03 AM, documented Resident #6 had a stage II pressure area to her coccyx with measurements of 1.5 x 1.5 x 0.2 cm. The report directed staff to lay Resident #6 down after every meal and continue with the barrier cream. The physician was not notified of the pressure ulcer and the care plan was not revised to have Resident #6 lay down between meals. A Skin Ulcer Non-Pressure Weekly report signed by the wound nurse, dated 9/26/18 at 8:43 PM, documented Resident #6 had MASD to the sacrum with measurements of 1.2 x 0.5 x 0.1 with scant amount of sanguineous drainage (thin, watery, and pale red to pink in color). The wound bed was pink with undefined wound edges. A weekly Skin Evaluation report, dated 10/1/18 at 11:03 AM, documented Resident #6 had a pressure ulcer to her sacrum with measurements of 1.5 x 1.5 cm and staff continued to apply barrier cream to the pressure ulcer. A Skin Ulcer Non-Pressure Weekly report signed by the wound nurse, dated 10/3/18 at 10:38 PM, documented Resident #6 had MASD to her sacrum with measurements of 2.0 x 0.7 x 0.1 cm. The wound nurse documented, partial, 90% slough (dead tissue, usually cream or yellow in color) noted to area. No redness surrounding tissue. The Skin Ulcer Non-Pressure Weekly report documented site 2 with an onset date of 10/3/18 to Resident #6's left buttock had MASD with measurements of 0.4 x 0.4 cm with 100% red granulation noted to the wound bed and the wound edges were undefined. The weekly Skin Evaluation report, dated 10/8/18 at 11:03 AM, documented Resident #6 had MASD to her sacrum with measurements of 1.5 x 1.5 x 0.1 cm. A Skin Ulcer Non-Pressure Weekly report signed by the wound nurse, dated 10/10/18 at 11:21 AM, documented Resident #6 had MASD to her sacrum with measurements of 1.5 x 0.5 x 0 cm with partial thickness to the wound. The weekly Skin Evaluation report, dated 10/15/18 at 7:00 AM, documented Resident #6 had an open area on her sacrum. There were no measurements documented. A Skin Ulcer Non-Pressure Weekly report signed by the wound nurse, dated 10/16/18 at 10:10 AM, documented Resident #6 had MASD to her sacrum with measurements of 1.4 x 0.4 x 0 cm. The wound bed was pink with partial thickness and the wound edges were undefined. On 10/23/18 at 10:35 AM, the DNS stated the wound nurse was on vacation and she would complete the weekly Non-Pressure report this week for Resident #6. The DNS was observed assessing Resident #6's sacrum. The DNS stated Resident #6 had a stage III pressure ulcer to her sacrum. The DNS stated the measurements were 1.5 x 0.6 x 0.2 cm. The wound bed had 75% slough with granulation tissue, wound edges were defined with a scant amount of sanguineous drainage. The DNS stated she was going to notify the physician for new treatment orders. The DNS stated the current order for [MEDICATION NAME] was not effective and the physician should have been notified on 8/11/18 when Resident #6 developed the pressure ulcer to her left buttock. The DNS stated the wound nurse and the nurses were not certified in wound treatment and needed to be educated on evaluating wounds, location of the wound, and staging wounds. 2. Resident #2 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #2's admission MDS assessment, dated 2/27/18, documented she was moderately cognitively impaired and required one person limited assistance with bed mobility and transfers. The MDS assessment documented Resident #2 was at risk for pressure ulcers and had no unhealed pressure ulcers. Resident #2's care plan, initiated on 3/14/18, documented Resident #2 had MASD to her abdominal folds. The care plan interventions included to keep her skin clean and dry and to provide treatments as ordered by the physician. A Nurse's Progress Note, dated 3/19/18 at 1:12 AM, documented Resident #2 had two open area to her left buttock. A physician's orders [REDACTED].#2's left buttock every shift for treatment of [REDACTED]. Resident #2's (MONTH) (YEAR) TAR documented her skin was assessed each Tuesday. The TAR documented Resident #2 skin was intact on 3/6/18, 3/13/18, and 3/20/18. On 3/27/18 the TAR documented Resident #2 had skin breakdown. The TAR instructed staff to complete an assessment of the skin breakdown, if it was present. Resident #2's clinical record did not include an assessment of the skin breakdown noted on 3/27/18. Resident #2's (MONTH) (YEAR) TAR documented [MEDICATION NAME] barrier cream was to be applied three times a day to the open area on her left buttock. The TAR did not include documentation the barrier cream was applied during 4 of 39 opportunities. Resident #2's (MONTH) (YEAR) TAR documented weekly skin assessments were completed. On 4/3/18 and 4/10/18 the TAR documented breakdown of Resident #2's skin. Resident #2's clinical record did not include assessments describing Resident #2's skin breakdown on 4/3/18 and 4/10/18. On 4/17/18 the TAR documented Resident #2's skin was intact. Resident #2's (MONTH) (YEAR) TAR documented [MEDICATION NAME] barrier cream was to be applied three times a day to the open area on her left buttock. The TAR did not include documentation the barrier cream was applied during 4 of 58 opportunities. A Nurse's Progress Note, dated 4/2/18, documented the physician assessed Resident #2. The progress note did not include documentation the open area on Resident #2's left buttock was assessed by the physician or orders for the treatment of [REDACTED]. A physician's orders [REDACTED]. The wound clinic progress note, dated 4/20/18, documented Resident #2 had stage III pressure ulcers on the buttocks and posterior thighs. The wound clinic progress note documented There are 4 ulcerations present on the right buttock with the largest being 2 cm x 1 cm, and 2 small ulcers on the left upper buttock. On the right posterior thigh, there is a large ulcer covered in adherent [MEDICATION NAME] (fibrous protein involved in the clotting of blood) measuring 3.6 cm x 1.2 cm with an unmeasurable depth due to [MEDICATION NAME]. The wound clinic progress note documented Resident #2 had stage III pressure ulcers to bilateral posterior heels with at least two on each side. The wound clinic progress note documented The largest is on the left posterior heel and measures 1.8 cm x 1.3 cm with a depth of 0.2 cm, covered in adherent [MEDICATION NAME] and eschar (dry, dark dead tissue). Resident #2 was sent to the emergency room from the wound clinic on 4/20/18 and did not return to the facility. On 10/23/18 at 12:00 PM, the DNS stated Resident #2's clinical record lacked documentation of wound measurements or descriptions of the wounds that developed to stage III pressure ulcers. The DNS stated the facility did not complete the required skin assessments when Resident #2 developed pressure ulcers.

Based on observation, staff interview, and record review, it was determined the facility failed to ensure a medication prescribed for [MEDICAL CONDITION], had adequate indications for use; was adequately monitored; was not administered at an excessive dose; and was reduced or discontinued when the resident experienced adverse consequences to the medication. This was true for 1 of 4 (#4) sampled residents. Resident #4 was harmed when he experienced nausea/vomiting, increased weakness, increased confusion and delusions, and tremors related to [MEDICATION NAME]. Findings include: Resident #4 was discharged from the hospital and admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A Hospital Discharge Summary, dated 12/24/15, documented, The patient's dementia has not been worked up consider referral to neurology for further work-up as outpatient. A Social Service Evaluation, dated 12/24/15, documented, Resident can be demanding and difficult to work with. Resident struggles with cognition deficits. He is capable of making decisions but is often confused about facts. He is rigid and wants things to go his way. He lacks patience and flexibility but his stubbornness is manageable. Social Service notes from 1/4/16 to 3/8/16 documented: * 1/4/16 - Upon assessment of the resident's cognition it was determined the resident suffered from moderate impairment. The resident was assessed three additional times after admission and his score went up. The resident's clinical record did not include the three additional assessments nor did it document any additional information regarding the resident's cognition. The Admission MDS, dated [DATE], coded the resident had difficulty hearing, usually had the ability to understand others and to be understood, moderate memory impairment, periodic disorganized thinking, felt down depressed or hopeless, felt tired or had little energy, felt bad about himself, and had trouble concentrating. The current care plan documented Resident #4 had a recent illness and deconditioning in the home setting which led to a decline in cognition. Interventions included: Encourage communication as a way to improve memory; ask about past experiences to assist with long-term memory; and assist resident with finishing his thoughts as needed. On 3/14/16, the following intervention was added, If resident rambles to other subjects allow him to talk and then redirect. A neurology consult, dated 2/9/16, documented, the resident was doing very well up until November and stated he has had mild problems with memory for about the last two months . He reports no family history of dementia and complained of generalized weakness and increased confusion for the last 3 days. He reported flu-like symptoms as have many people at the facility. He is not on medications for dementia and does not report psychotic symptoms. He scored a 9/30 on his MMSE. (According to the Alzheimer's Society the MMSE is used to assist in the assessment of dementia and is only one part of the assessment.) Based on the limited amount of information available, it appears the patient suffers from [MEDICAL CONDITION] and is in the moderate to severe stage of this. As the patient reports that he is feeling ill and confused, it is unclear if his score today on the MMSE represents his true baseline. It is recommended that this be repeated by his physician when he is feeling better, and prior to final determination regarding competency. [MEDICATION NAME] and [MEDICATION NAME] may provide some benefit . Nurses Notes from 2/9/16 to 3/7/16 documented two occurrences of increased confusion for Resident #4: a. On 3/5/16 at 12:30 pm, the resident was alert with confusion to time and situation and not easily re-oriented. b. On 3/6/16 R 1:00 pm, the resident was alert with less confusion than the day before. Physician Visits for 2/9/16 and 3/7/16 documented: a. 2/9/16 - Probable dementia of the Alzheimer's type with a score of 9/30 on MMSE. Performance may have been affected by an intercurrent (sic) illness, UA pending. b. 3/7/16 - Staff has noticed he has been angry. Patient is very talkative today but fixated on recent visit with (Physician's name) and the forms he had to fill out. He denies other particular problems, although he is a very poor historian. His visit with neurology was reviewed and he scored a 9/30 on MMSE and either [MEDICATION NAME] or [MEDICATION NAME] were recommended. The note did not include whether a repeat MMSE assessment was completed prior to the initiation of the [MEDICATION NAME]; whether a risk and benefits had been discussed with the resident; and whether there was input from the resident. A Physician Order, dated 3/7/16, documented a new order for [MEDICATION NAME] 23 mg by mouth daily. The FDA and 2015 Manufactures specifications, for dosage and administration of [MEDICATION NAME] documented: a. Dosing in mild - moderate [MEDICAL CONDITION] - The recommended starting dosage for [MEDICATION NAME] is 5 mg administered once per day in the evening, just prior to bed. The maximum recommended dosage is 10 mg per day. A dose of 10 mg should not be administered until patients have been on a daily dose of 5 mg for 4 to 6 weeks. b. Dosing in moderate - severe [MEDICAL CONDITION] - The recommended starting dosage of [MEDICATION NAME] is 5 mg administered once per day in the evening prior to bed. The maximum recommended dosage is 23 mg per day. A dose of 10 mg should not be administered until patients have been on a daily dose of 5 mg for 4 to 6 weeks. A dose of 23 mg per day should not be administered until the patients have been on a daily dose of 10 mg for at least 3 months. c. The most common adverse reactions for patient's receiving [MEDICATION NAME] 23 mg daily include vomiting, nausea, dizziness, anorexia, fatigue, somnolence, depression, and has the potential to cause hallucinations. The March 2015 MAR indicated [REDACTED] a. The resident received the first dose of [MEDICATION NAME] on 3/8/16 and from 3/9/16 to 3/12/16 and 3/14/16. b. The resident refused the [MEDICATION NAME] on 3/13, 3/15 and 3/16/16. The documented refusals did not include an explanation or reason for the refusals. c. The MAR indicated [REDACTED]. Nurses Notes from 3/9/16 to 3/14/16 after the [MEDICATION NAME] was initiated documented: a. 3/9/16 at 1:00 am - Resident #4 was tearful, wanted to talk with staff, and told them they were special. b. 3/9/16, day shift - Updated the resident's POA regarding Resident #4's increased signs and symptoms of depression, seeing God, and new order for [MEDICATION NAME]. c. 3/10/16, day shift - Resident with large incontinent bowel movement and multiple periods of confusion. d. 3/11/16, day shift - Resident with emesis x 1 today and increased weakness and confusion. Called POA (and) explained decline in resident's condition and concerns regarding him passing away. e. 3/12/16 at 11:00 am - Resident verbalized nausea/vomiting; experienced increased confusion; started having delusions and accusing staff of poisoning his food; would not follow directions; could not be redirected; and developed tremors in his extremities. f. 3/14/16 at 4:00 pm - Resident experienced increased weakness; decreased level of consciousness; decreased strength; and decreased oral intake. On 3/16/15 at 10:00 am, the resident discussed many areas of his life including his military service during WWII and how he was wounded when a piece of shrapnel hit him in the head; how he met his wife; his children; his life as a physician; his ranch with his log cabin home; and his current business venture. On 3/17/16 at 2:25 pm, when asked if the facility requested the Social Service consultant to evaluate Resident #4's memory impairment, the Administrator and DNS stated they had not asked, but should have. The Administrator stated they were concerned the memory issues were related to the resident's current medical conditions and would improve with time. When asked if the facility questioned the [MEDICATION NAME] dose, the DNS stated she thought about it but did not pursue it with the physician and should have. When asked if the nurses were monitoring the medication for adverse side effects, the DNS stated they were not and should be. On 3/17/16 at 3:55 pm, via telephone interview with the resident's physician, when asked if it would have been important to address and resolve the resident's medical concerns prior to initiating the [MEDICATION NAME]; how it was determined the benefits of this medication were greater than the risks; and if the resident's baseline cognition had been assessed, the physician stated, If you want to know that you need to read the neurology evaluation and ask the neurologist. I can't speak to what he was thinking. I prescribed the [MEDICATION NAME] based on his recommendation. When asked why the resident was started on 4.5 times (23 mg) the manufactures recommended dosage, the physician stated, If I started the resident on that dose (23 mg) it was a mistake and it should have been started at the lower dose (5 mg). The physician then directed the surveyor to change the order to the lowest dose. The surveyor informed the physician the order would have to be given to a nurse at the facility. The DNS, who was present for the interview, informed the physician she would take the order. The physician stated, I am on vacation and I am driving right now so I can't look up the dose, just put him on the lowest dose and I will address it when I get back. When the DNS asked the physician if she would consider discontinuing the medication or holding the medication related to the resident experiencing adverse effects, the physician indicated she did not want the medication held and the resident should be transported to the hospital if he experienced dehydration related to nausea/vomiting/ diarrhea from the [MEDICATION NAME]. On 3/18/16 at 9:05 am, the facility's pharmacist stated he would not question the physician's orders [REDACTED]. He stated the pharmacy would check the new medication with the resident's current medications for possible drug interactions. The pharmacist stated the facility's consulting pharmacist would be responsible for reviewing the resident's record and addressing potential concerns regarding the dosage. When asked if [MEDICATION NAME] should be started at 23 mg, the pharmacist stated, No, it should have been started at the lowest dose, 5 mg and then titrated up if necessary. When asked if increased weakness; decreased level of consciousness, decreased strength, decreased oral intake, nausea/vomiting, increased confusion, new onset delusions, and tremors could be associated with such a high dose of [MEDICATION NAME], the pharmacist stated, Absolutely.

Based on observation, staff and family interview, and record review it was determined the facility failed to ensure 2 of 4 (#1, #9) residents reviewed for pressure sores did not develop pressure sores, or that the facility had interventions implemented to prevent pressure sores. Resident #1 was admitted to the facility without a pressure sore, but was harmed when the facility failed to implement interventions to ensure the resident did not develop pressures sores. On 3/5/14, the resident developed an unstageable, black SDTI (suspected deep tissue injury) to her right heel, which had reportedly healed. On 11/19/14, during the survey, the resident was observed with a recurrent, unstageable, purple area of concern to the right heel. Additionally, Resident #9 was care planned to have protective boots to prevent the development of pressure, however the protective boots were not provided to the resident. Findings include: Quick Reference to Wound Care Palliative, Home, and Clinical Practices 4th Edition; Copyright 2013, Edited by Pamela Brown. Page 88 and 89 documented: "Pressure Ulcer Stages Revised by NPUAP (National Pressure Ulcer Advisory Panel) 2007 SDTI and Unstageable Pressure sores: SDTI: A purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and / or shear may indicate deep tissue injury... Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by... and/ or eschar (tan, brown, or black) in the wound bed." 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's nursing admission assessment dated [DATE], documented "redness noted to coccyx area. ...redness noted to inner (and) outer (left) knee from prosthesis. (Right) foot (with) charcot deformity." NOTE: The assessment did not document the resident had skin concerns to the right heel. The resident's Norton Plus Pressure Ulcer scale form, used to predict risk of development of a pressure ulcer, dated 2/2/14, scored the resident high risk. The resident's admission MDS dated [DATE], documented the resident's cognition was severely impaired; bed mobility was extensive assistance of two people; at risk to develop a pressure sore; no pressure sore on admit and had a pressure reducing device to bed and chair. The resident's care plan dated 2/9/14, documented the resident had a potential for skin break down related to poor intake, hydration and decreased mobility. The interventions included elevate right leg at times to prevent [MEDICAL CONDITION] and skin prevention (hand written at the side of the intervention); assist with turning and repositioning for comfort as needed as resident tolerates; report redness to LN; and pressure reducing device to bed and wheelchair. On 2/22/14 a new intervention was added to the care plan for the resident to wear an AFO/shoe to right foot ... NOTE: The care plan documented the right leg was to be elevated at times, with no guidelines as to when to elevate the leg and float the heels for protection of the heel and to turn and position as needed (no time frame provided). The care plan did not direct staff to monitor the AFO brace for position of the foot when the resident was up in her wheel chair, tightness, or pressure areas. An I & A (Incident and Accident) report dated 3/5/14, 7:00 AM, documented a change in the resident's condition written by the LN, "Black blister noted to back of (right) heel 3 cm (centimeter) round.... Will start some new approaches to her care. Has had her boot for a couple years." A CNA documented, "(Resident's name) was laying in bed.... Right leg had nothing on no pillow (sic) foot was just laying on bed." A second CNA documented, "... No we did not turn her side to side and yes she did move her foot when we would prop her foot upon a pillow and when we went in again for our rounds she had moved her leg off the pillow." The DON invesigation summary documented, on 3/4/14, the resident had been assisted from bed and her AFO brace was on the right foot. The resident was observed by the activity director with her right heel resting on the end of the foot rest and the activity director was unable to tell how long the foot had been resting on the device or whether the resident had hit her heel when she positioned it on the foot rest. The DON documented the resident moved her right foot up and down in the bed and her right leg had been off the pillow during rounds, and documented, "... If there was an injury from earlier, the rubbing would have added to the blister / deep tissue injury site." The use of the electric wheel chair with the foot rest was new to the resident since admission to the facility. NOTE: The facility was aware the resident did not keep her foot floated on the pillows and did not implement new measures to ensure the heel was floated and protected from pressure or friction from rubbing on the bed until after the black blister was identified on the right heel. Prevalon boots were implemented, however the facility failed to identify or assess the new wheelchair for potential skin concerns. The resident's Wound/ Skin report (WSR), Nurse's notes (NN), physician progress notes [REDACTED]. *WSR 3/5/14 at 7:15 AM: The right heel had a 3 cm, round, black blister, a Stage II SDTI (suspected deep tissue injury.) NOTE: According to the NPUAP (National Pressure Ulcer Prevention Panel) a black blister is considered "unstageable." The LN documented the black blister as a Stage II pressure ulcer. *NN 3/5/14 0730-11:00 AM: "(No) [MEDICAL CONDITION] noted to R (right) foot.... Air Mattress (and) bed changed out...." *CCF 3/5/14: "...noted afternoon Pitting [MEDICAL CONDITION] in R (right) foot (and) ankle today. (And) (no) feeling in Rt. foot." The resident's November 2014 physician orders [REDACTED]. Start date: 3/5/14. NOTE: The resident was at high risk for skin breakdown. The air mattress and Prevalon boots were not ordered until after the resident's right heel developed a black blister. The resident's care plan was updated on 3/5/14, with a focus problem for impaired skin integrity related to the black blister on the right heel. New interventions implemented included air mattress; Prevalon boot while in bed; treatment as prescribed; turn every 2 hours, and float right heel while in bed. The AFO/ shoe to right foot was placed "on hold." *PPN 3/7/14: The resident was seen in the office to establish care for eleven medical conditions, #10 was "R (right) heel wound: She has charcot's foot deformity and usually wears a brace. This is a tight brace and may be a culprit for her wound...." The physician progress notes [REDACTED]." NOTE: The physician documented the wound to the right heel was necrotic tissue. The traction boot was tight and may have contributed to the wound and the boot needed to be padded. The facility had not documented an assessment of the AFO to ensure the brace properly fit the resident from the time of admission to the facility. *NN 3/8/14: "...skin prep to necrotic blister on heel. Skin remains intact - other edges remain firm and pink...." *CCF 3/11/14: "...Most of the fluid in blisters feels like it is gone. ...(Right) inside ankle has 0.1 cm x 0.3 cm dk (dark) pink area. Skin prep applied to both sites." *WSR 3/11/14: Stage II, irregular; size: 3 cm L (length) x 2.5 cm W (wide), depth: unknown; wound bed: black. *NN 3/12/14: "...Rub area to inner ankle still dark pink. A transfer boot (not) used today." The resident's care plan was updated on 3/12/14 to include the problem of impaired skin integrity related to [MEDICAL CONDITION] and high risk skin. The interventions included padding to the electric wheel chair foot rest. *WSR's 3/20, 3/25, 4/2, 4/9, 4/16, 4/30, 5/7, 5/14 and 5/21/14 had similar documentation that the wound had decreased in length and width, depth was still unknown and the wound bed was described from black to purple to a scab. *CPU 3/25/14: Skin integrity on the right medial ankle continued to be a care issue with the right heel. Healing the right medial anjkle continued to be the goal. *CPU 3/26/14: Implemented an intervention for frequent turning. The resident's TAR (Treatment Administration Record), dated 3/1/14 through 3/31/14, documented: * Prevalon boots on while in bed from 3/5/14. The boots were not documented as being on the resident on 3/17, 3/29 and 3/30/14 on evening shift and on 3/25 on night shift. *Skin prep to right heel blister area: The treatment was to be provided on day shift. Treatment was not documented as provided on 3/26, 3/27, and 3/28. *WSR 5/28/14: The wound had "deteriorated" and was 1.4 cm by 0.4 cm by 0.2 cm, and the wound bed was described as "scab". Comments: "Heel becomes worse (with) each UTI (urinary tract infection)- then starts healing." *WSR 6/3/14: The wound was 1.0 cm x 0.8 cm; Depth: unknown; Wound bed: Scab; "Improved." *WSR dated 6/11, 6/18, 6/24, 7/2, 7/9 and 7/16 documented the wound in length, width, and depth; the wound bed; and that the wound had "improved." *WSR 7/23: The wound had "deteriorated." Size: 0.12 cm L x 1 cm W; Depth: unknown; wound bed: scab; "Becomes enlarged (with) UTI's. Will monitor." The resident's July 2014 TAR documented skin prep was provided to the resident's right heel area to "toughen" the skin in that area. The treatment was not documented as provided on 7/5, 7/6, 7/23, 7/24, 7/25, 7/26, 7/27, 7/29 and 7/31. NOTE: The treatment was not documented as provided on 7/23/14 when the LN had documented the wound had deteriorated. *WSR 7/30: The wound had "improved." Size: 0.3 cm L x 0.9 cm W. Depth: Unknown; Wound Bed: scab. NOTE: The length of the wound had doubled in size from 7/23 to 7/30/14 and the LN documented the wound had "improved." The TAR documented the resident received treatment to the wound once only from 7/23 through 7/31, with the treatment documented as performed on 7/30, the day of the WSR. *WSR 8/13: The wound was documented as "improved." Two areas of breakdown were documented as follows: Size: 0.2 cm L x 0.3 cm W, and 0.2 cm L x 0.1 cm W; Depth: sup(erficial); Wound bed: Pink. Comments: "0.2 cm in center healed." NOTE: This was the only documentation of two open areas on the resident's heel and the facility had documented the wound had improved with two superficial open areas; previous documentation was for one wound. The WSR documented assessments on 8/19, 8/27, and 9/3 with fluctuating length and width from decreased to increased in size, and depth from superficial to greater than 0.1 cm. The WSR documented on 9/10 and 9/17 the wound was healed. The resident's November 2014 TAR documented; *Prevalon boots to right foot every shift for skin breakdown. On evening shift, the boots were not documented as being on the resident on 11/3, and 11/15/14. *Right heel apply A and D ointment every shift to prevent opening. Start date: 11/19/14. On 11/18/14 at 9:00 AM, CNA #2 and CNA #3 were observed providing cares for the resident and assist her to bed. The CNAs were asked if the resident's heel had an open area at this time. CNA #3 stated, "I don't think so." CNA #2 stated the boots were for protection. The resident was positioned on her right side with the blue Prevalon boot on. The right foot was not floated. On 11/18/14 at 10:20 AM, the resident was observed in the same position. On 11/18/14 at 6:00 PM, the resident was observed in bed on her back and her family member was at the bedside. The resident's right foot had a beige sock on, and the Prevalon boot was not on the foot. The right heel was directly on the bed. The family member was asked if she had taken off the Prevalon boot and she stated, "No, I took off her shoe. I don't like her to have the boot on in bed. I think they have it on her during the day." The family member stated she had put her mother to bed. On 11/19/14 at 10:40 AM, the resident was observed in bed propped on the right side with a pillow behind the left side of her back. The blue boot was on the right foot, the heel was not floated. On 11/19/14 at 11:15 AM, the resident was observed in bed with LN #1, CNA #2 and CNA #3 in the room. LN #1 was asked if the resident had been admitted with the black blister, and she stated, "No, it was acquired here." The blue boot was removed from the right foot and LN #1 observed the heel. The LN identified an area to the back of the heel and stated, "It is not open which is a good thing." She was asked if the area blanched and she stated, "Not very good but it does blanch." The LN was asked what color it was and she stated, "It is a purple area." The LN was asked how big the area was in March and she stated, "It covered the heel. It was purple -black in the beginning. It was huge." When asked when the Prevalon boots were implemented, LN #1 stated, "When it started" in March. The LN left the room to retrieve a tape measure to measure the area. The CNA's were asked if the bed was inflated and was it an air bed. CNA #3 stated it was a new bed they had received about a month prior. The two CNAs looked for a setting on the bed and CNA #2 opened the cover on the foot of the footboard of the bed. There was a control panel with options for "firmer, softer, pressure relief, comfort, 1. heel relief, 2. heel relief, 3. heel relief." None of the controls were on or lit up. The CNA pressed the pressure relief option and the bed made an instant puff of air sound, which then inflated the bed with air. The CNA's were asked if they checked the bed to ensure pressure relief was on. CNA #3 stated she would not know how to check it and CNA #2 stated she would not have thought to check if the air mattress option was on. Outside the panel on the bed a green light came on which had "pressure relief" beside the light. The LN, who had returned to the resident's room, verified the bed did not have air protection when it was not on pressure relief mode. The LN was asked if anyone was responsible to check if the bed was in pressure relief mode, and she stated she was not aware of anyone being responsible to check the bed. She stated, "Probably the nurse or CNA should check it at least once every day." The LN was then asked if the resident had a pressure sore to her feet before coming to the facility, and she stated, "That is how she lost her other leg." The LN was asked if the resident should be considered high risk with preventive measures implemented upon arrival to the facility. The LN stated, "She was high risk over all, the (family member) has a way of doing things." The LN was asked if the family member had been educated on preventive measures when the resident arrived and was it documented, to which she stated, "I am sure there should be," (documentation). On 11/19/14 at 3:00 PM, the resident was observed in bed with a blue protective boot on and the right heel floated off a pillow. CNA #4 stated the resident's family member often put the resident to bed at night and as the evening CNA she would go in to check the resident around 6:30 PM and the protective boot would not be on. CNA #4 stated, "So we put the boot on and tell the (family member) it needs to be on for pressure relief." The CNA was asked if she checked the bed to verify the bed was on pressure relief mode and she stated, "I have never checked the light or the switch to verify the bed was on. I just push on the bed and feel if it goes down and comes back up." The bed was observed to have the green light on for pressure relief and heel relief. On 11/19/14 at 4:15 PM, the DON was asked to describe what the facility implemented when the resident arrived to prevent pressure sores as she was documented as high risk and had lost her left leg due to a pressure sore. The DON was also asked whether the facility had assessed the brace for proper fit and protection prior to the development of a black blister in March. The DON stated the resident's brace was flexible over the heel and the heel rested on the "hard spot" of the heel, and that up to that point the resident did not have redness to the heel. It was a very narrow time line. The DON verified the resident's new bed was received approximately one month earlier, but said she wasn't sure whether staff had been in-serviced on its operation. *CCF 11/19/14: "(Right) heel was a 0.3 cm x 1.0 cm dk (dark) purple area. A and D applied - Area around blanches poorly. Unstageable. ....(unknown depth). (Family member) talked to about bed. Will be in to learn about pressure relief on bed. Explained need for Provolon (sic) boot (and) use." *CPU 11/19/14: Problem focus are skin integrity impaired, related to (right) heel unstageable purple area. Goal: (Right) heel will return to pink color (without) opening. Interventions included ensuring air mattress was inflated; show (family member) how to use the bed; ensure Prevalon boots are on; monitor every week and treatment as prescribed. On 11/20/14 at 3:45 PM, the DON verified the brace had not been assessed by Physical Therapy or facility staff prior to the black blister appearing in March. The DON was asked if the intervention on the care plan that stated to elevate the right leg was the same as float the heels and she stated, "It was assumed and did not specifically say float the heels." When staff documented the resident did not keep her feet on the pillows, the DON was asked whether the facility considered using the Prevalon boot or other interventions prior to the heel skin breakdown. The DON stated, "We did not tie it to pressure in the bed; we felt like it was an injury, not pressure from the bed." When asked to describe the bed in place prior to the resident's receipt of the new bed, the DON stated, "...a regular air mattress." When asked whether there was documentation that staff had been trainin on the bed and the different modes possible with it, the DON stated, "No, we never did an inservice." On 11/21/14, at 11:00 AM, the Administrator and DON were informed that Resident #1 who was admitted to the facility as high risk to develop a pressure sore, had been harmed when she developed an unstageable black blister in March 2014. The resident's right AFO foot brace had not been assessed by the facility for proper fit, or potential pressure areas. The resident was provided a new electric wheelchair, which had not been assessed for potential pressure areas, and the resident had been observed with her foot not floated on a pillow. The resident developed a new purple, unstageable area of concern to the right heel, which was discovered during survey on 11/19/14. At the time of discovery the resident's new air bed did not have the pressure relief function turned on and the staff had not been in-serviced on the bed's various operational modes. On 11/24/14, the facility provided the following additional information: The resident was seen by her physician on 11/21/14. The progress note resulting from the physician's visit documented an evaluation of the resident's right foot with an area of concern on the posterior aspect of the heel. The MD Progress Note documented, "No evidence of deep tissue injury. Normal temperature and blood flow.... Previous scar tissue. Continue padding of heel." This information did not change the findings. The resident's heel was observed by the LN on 11/19/14, two days prior to when the resident was seen by the physician. The LN, who the facility designated to provide wound/skin assessments, assessed that wound was "unstageable," blanched poorly, was purple, and the resident was in a bed that was not in its pressure-relieving mode when the area of concern was discovered. 2. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's 11/1/14 Physician order [REDACTED]." The resident's 12/14/13 Care Plan for skin integrity included an intervention, dated 9/9/14, for "foam boots when in bed. Heel float boots when up as needed." On 11/19/14 at 3:15 p.m., the resident was observed sitting in a recliner with a pillow under her legs to elevate her heels off the recliner. A pair of heel boots were observed laying on her bed. On 11/20/14 at 11:55 a.m. the DON looked at the physician orders [REDACTED].

Based on resident, staff, and family interviews; record review, review of abuse policies and procedures, and review of abuse investigation reports; it was determined the facility failed to develop and/or operationalize its abuse policies and procedures when they did not: * Develop policies to ensure residents were protected from exposure to employees who had been accused of abuse; * Ensure residents and/or resident representatives were informed of the outcome of investigations of abuse allegations; * Investigate all allegations of abuse; * Protect all residents when an allegation of abuse should have been investigated and the alleged perpetrator continued to work in the facility; * Ensure that all allegations of abuse/neglect and investigation results were reported to the state survey and certification agency in accordance with state law; * Ensure residents/Interested Parties were not afraid to report allegations of abuse/neglect because of fear of retaliation and intimidation; and, * Ensure contract staff were trained regarding abuse policies and procedures. This was true for 1 of 10 sample residents (#2). Failure to operationalize the abuse policies and procedures placed Resident #2 and all other residents who lived in the facility at risk for abuse. These failed practices constituted immediate jeopardy to the residents' health and safety. Findings included: 1. Resident #2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Hospice services were also initiated on 8/3/13 due to the [DIAGNOSES REDACTED]. Resident #2's most recent admission MDS, dated [DATE], documented in part: * Cognitively intact with a BIMS score of 15; * Usually able to make self understood; * Able to understand others; * Extensive assist with one person for bed mobility, transfer, dressing, and personal hygiene; * Extensive assist with 2 people for toilet use; and, * Functional limitation in range of motion in both upper and lower extremities. Resident #2's August 2013 Plan of Care identified problem areas and interventions included: * ADL - Pancake call light. Staff to assist as necessary * Bladder Incontinence - Encourage resident to seek assistance with toileting and keep call light in reach; * Altered thought process due to Supranuclear Palsy which inhibits her ability to speak or process quickly - Determine if delayed reaction to information is due to misunderstanding or communication delay, and allow plenty of time for resident to respond to questions. Resident talks very softly, please ask resident to restate if needed; and * Potential for falls - Keep call light within easy reach, use easy touch style pancake call. On 8/28/13 at 10:15 a.m., during an interview, Resident #2's Interested Party stated they had been informed by Resident #2 that a CNA had thrown the call light at her. The Interested Party indicated this occurred a week or so after Resident #2 was admitted to the facility. The Interested Party added that they were afraid to tell anyone about the incident because they were "Afraid of retaliation." A hospice CNA who was in attendance at the time stated that she too was afraid of retaliation. On 8/28/13 at 11:40 a.m., the hospice CNA was interviewed. When asked to explain what made her feel afraid of retaliation she stated, "You kind of get an aura," and began telling the surveyors about a previous resident she had cared for at the facility earlier in the year. The hospice CNA stated this previous resident confided in her details of a night when the resident heard what she called, "Love making" in the empty bed in the resident's room. The hospice CNA stated the "Resident said, 'Please don't say anything'" because the resident was "Mortified they weren't going to answer the call bell, toilet her, etc," if a report was made. The hospice CNA stated she reported it to the hospice LN, as well as LN #3, then to the administrator about 25 minutes later. The hospice CNA stated the resident said, "I wish you didn't say anything." The hospice CNA was asked if she was asked by the facility to provide a written statement about the incident and she stated, "No. It was verbal, cordial. I don't remember signing any kind of document." The hospice CNA was asked if she was trained on abuse by the facility. The CNA stated, "No. I remember from schooling." On 8/28/13 at 2:20 p.m., Resident #2 was asked about the incident with the CNA and call light. The resident stated, "She (CNA #1) threw the call light at me and said, 'Here is your call light (residents name).'" Resident #2 continued, "She (CNA #1) hasn't been the same since, grumpy towards me." The Resident was asked if she reported the incident to anyone and she stated she told her family member who then talked to the Administrator. Resident #2 was asked if she was afraid to inform staff of the incident she stated, "No." When asked why she didn't notify staff, Resident #2 stated, "I'm not a teller." On 8/28/13 at 2:50 p.m., the Administrator was asked to provide documentation of an investigation report regarding the allegation of abuse to Resident #2. The Administrator stated the incident occurred "Two or three weeks ago," and that an evening CNA had complained to her that CNA #1 wasn't nice to Resident #2. The Administrator said she met with Resident #2 and an Interested Party about the allegation of abuse and asked them, "Do you want to write out a formal grievance, and they said no." The Administrator added, "I didn't treat it as a formal grievance. I said, 'Did she truly throw it at you?' And she (Resident #2) said, 'No.'" When asked if there was any documentation about the discussion between the Administrator, Resident #2, and the resident's Interested Party, the Administrator stated, "No. It was more that she felt the aide wasn't being nice, was ignoring her. I guess I should have went through each of those steps." The Administrator continued, "Maybe she's (CNA 1) not always the nicest, or seems as caring. What I did is I brought her (CNA #1) in and asked her if something was going on. I think there was an issue with her attitude." The Administrator continued, "She's been working here all along." When asked if there was counseling or reprimand in CNA #1's file, the Administrator stated, "No. I verbally talked to her but I didn't write up anything." The facility's Abuse Investigations Policy, 2001 revised 2004, documented in part: * Policy Statement - All reports of resident abuse, neglect and injuries of an unknown source shall be promptly and thoroughly investigated by facility management; * Policy Interpretation and Implementation: * Our facility is committed to protecting our residents from abuse by anyone including but not necessariliy limited to: facility staff, other residents...and staff from other agencies providing services to our residents; * Should an incident or suspected incident of resident abuse, neglect or injury of an unknown source be reported, the administrator, or his/her designee, will appoint a member of management to investigate the alleged incident; * The administrator will provide to the person in charge of the investigation a completed copy of the "Resident Abuse Report Form" and any supporting documents relative to the alleged incident; * The individual conducting the investigation will, as a minimum: * Review the completed "Resident Abuse Report Form;" * Review the resident's medical record to determine events leading up to the incident; * Interview the person(s) reporting the incident; * Interview any witnesses to the incident; * Interview the resident (as medically appropriate); * Interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition; * Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; * Interview the resident's roommate, family members, and visitors; * Interview other residents to whom the accused employee provides care or services; and, * Review all events leading up to the alleged incident. * The following guidelines will be used when conducting interviews: * Each interview will be conducted separately and in a private location; * The purpose and confidentiality of the interview will be explained thoroughly to each person involved in the interview process; and, * Should a person disclose information that may be self-incriminating, that individual will be informed of his/her rights to terminate the interview until such time as his/her rights are protected. * Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports. (Note: A copy of such reports must be attached to the "Abuse Investigation Report Form."); * The individual in charge of the abuse investigation will notify the ombudsman that an abuse investigation is being conducted. The ombudsman will be invited to participate in the review process; * Should the ombudsman decline the invitation to participate in the investigation, that information will be noted in the investigation record. The ombudsman will be notified of the results of the investigation as well as any corrective measures taken; * While the investigation is being conducted, accused individuals not employed by the facility will be denied unsupervised access to residents. Visits may only be made in designated areas approved by the administrator. Policies governing visitation are outlined in a separate policy in this chapter entitled "Visitation;" * Employees of this facility who have been accused of resident abuse may be reassigned to nonresident care duties or suspended from duty until the results of the investigation have been reviewed by the administrator; NOTE: This policy does not specify how residents will be protected from exposure to employees who have been accused of abuse. This potential for further exposure places all residents at risk of further abuse while an investigation is being conducted. * The individual in charge of the investigation will consult daily with the administrator concerning the progress/findings of the investigation; * The administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation; * The results of the investigation will be recorded on the "Resident Abuse Investigation Report Form;" * The investigator will give a copy of the completed "Resident Abuse Investigation Report Form" to the administrator within 4 working days of the reported incident; * The administrator will inform the resident and his/her representative (sponsor) of the results of the investigation and corrective action taken within 2 days of the completion of the investigation; NOTE: At the time Resident #2 and the resident's Interested Party were interviewed on 8/28/13 they still had no follow-up from the incident they reported to the facility during the week of 8/3/13, a total of at least 19 days. * Should the investigation reveal that abuse occurred, the administrator will report such findings to the local police department, the ombudsman, the state licensing agency and others as may be required by state or local laws within 2 days of the results of the completion of the investigation; NOTE: The 2005-1 Informational letter on resident abuse reporting stated, "All allegations must be immediately reported to the facility's Administrator and to the Department's hotline...'Immediately' means as soon as reasonably possible, and no later than 24 hours from the discovery of the incident...All investigation reports must include the facility's conclusions and actions taken to prevent a repeat occurence of abuse." * The administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency within 5 days of the reported incident; NOTE: This conflicts with the aforementioned statement. * Should the investigation reveal that a false report was made/filed, the investigation will cease. Residents, family members, ombudsmen, state agencies, etc., will be notified of the findings; NOTE: The facility did not demonstrate any of those steps had been taken regarding Resident #2's allegation. * Policies governing abuse reporting are outlined in separate policies of this chapter entitled "Reporting Abuse to facility Management" and "Reporting Abuse to State Agencies and Other Entities/Individuals;" * Inquiries concerning abuse reporting and investigation should be referred to the administrator or to the director or nursing services. On 8/28/13 at 5:30 p.m., the Administrator and DON were informed of the immediate jeopardy issue related to the facility's failure to operationalize policies and procedures for training contract employees, protection of residents, and for the prevention, identification, investigation, and reporting of allegations of abuse, neglect, and mistreatment of [REDACTED]. On 8/30/13 at 8:45 a.m., the facility provided an acceptable plan to abate the immediate jeopardy. The abatement plan documented in part: * The Administrator and DON confirmed understanding of Federal Regulation; * The Administrator and DON updated the facility's Policy and Procedure for Abuse Investigations and Abuse Prevention Program, including federal guideline definitions and reporting processes; and, * The facility inserviced all staff, contract staff, and volunteers on the Abuse Policy and Procedures and reporting. Staff, contract staff, and volunteers not currently available will be inserviced prior to returning to work. The facility failed to follow its policy to investigate all allegations of abuse; failed to develop policies and procedures ensuring protection of residents or investigation and reporting of allegations of abuse, neglect, or mistreatment; failed to ensure residents were protected from further abuse when an allegation of abuse was not investigated; failed to reassign the employee to nonresident care duties or suspend from duty until results of the investigation were reviewed when an allegation of abuse was not investigated; failed to report the allegation of abuse; and failed to ensure contract staff (Hospice CNA) were trained regarding abuse policies and procedures. These failed practices placed all facility residents at risk for abuse, neglect, and mistreatment.

Based on staff interview and record review, it was determined the facility did not ensure a resident who entered the facility without pressure sores, did not develop pressure sores. This was true for 2 of 5 residents (#1 and 10) sampled for pressure ulcers. The deficient practice caused harm when Resident #1 developed multiple Stage II pressure sores. Findings included: 1. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #1's most recent quarterly MDS assessment, dated 7/2/13, coded: -Severely impaired decision making skills. -No rejection of cares. -Dependent on 2 persons for bed mobility, transfers, and dressing. -1 stage 2 pressure ulcer present, which was not present or present at a lesser degree on the previous assessment. Resident #1's care plan documented: -Required total assistance of 1 or 2 persons for bed mobility. -If resident is resistive, wait a few minutes and re-approach. -Approach several times if resistance continues. -Step away and re-approach if resident becomes agitated due to inability to communicate needs. -Observe ulcers on right and left heel, left little toe, start date listed as 3/13/13. -Pressure relieving air mattress, start date 2/7/13. -Foam boots on except when cares are being given, Prevalon boots on when in bed, start date 4/16/13. This approach also had a hand-written addition of, "Green boots when up", although no date was noted for this addition. -"Reposition routinely", start date 4/16/13. Resident #1's Norton Pressure Ulcer Scale Scores documented: 10/2/12 - Score of 6, indicating high risk for pressure ulcer development. 1/8/13 - Score of 6, high risk. 4/2/13 - Score of 9, high risk. 7/5/13 - Score of 9, high risk. Resident #1's Wound/Skin Record sheets contained spaces to document, at the date of each assessment, Stage, Size, and Depth of the wound; Response to Treatment; and Plan of Care Updated. Four wounds were documented for Resident #1. a. Wound A, onset date 1/8/13, 2 cm x 0.5 cm dark red area to right heel. -1/15/13 - Stage: "?" Size: "1 cm". Response to Treatment: "Improved." Plan of Care Updated and Depth were both blank. -1/24/13 - Stage, Depth, and Plan of Care Updated were all blank. Size: "1 cm. Response to Treatment: "Improved". -1/27/13 - Stage : "II", Size: "1 cm". Depth: "sup(erficial)." Response to Treatment and Plan of Care Updated were blank. -2/7/13 - Stage : "II", Size: "2 cm.' Depth".01" cm. Response to Treatment : "Deteriorated." Plan of Care Updated did not document a care plan update, but documented, "dry blister." -2/15/13 - Stage :"?" Size: "1 cm". Depth: blank. Response to Treatment: "Improved." Plan of Care Updated: "blister 1/2 off." -2/20/13 - Stage: blank. Size: "1 cm." Depth: blank. Response to Treatment: "Improved." Plan of Care Updated: "Blister off. Monitor for 1 (week)." -2/27/13 - Healed. (NOTE: The "Plan of Care Updated" section was blank or inaccurate 5 of 6 weeks.) b. Resident #1's Wound/Skin Record sheets documented for Site B, onset date 1/8/13, a 0.5 x 1.5 cm area to the left heel, documented as, "clear yellow drainage - open", with progression as follows: -1/15/13 - Stage and Plan of Care Updated were blank. Size: 0.5 cm. Depth: 0.2 cm. Response to Treatment : "Improved." -1/24/13 - Stage, Response to Treatment, and Plan of Care Updated were all blank. Size : 0.5 cm. Depth: 0.2 cm. -1/27/13 - Stage and Plan of Care Updated were blank. Size: 0.5 cm. Depth: 0.2 cm. Response to Treatment: "No Change." -2/7/13 - Stage: "II". Size: 2 cm. Depth: 0.1 cm. Response to Treatment: "Deteriorated." Plan of Care Updated: "Req(uest) for air mattress." -2/15/13 - Stage: "II", Size: 3.5 cm. Depth: 0.3 cm. Response to Treatment and Plan of Care Updated were blank. (NOTE: Even though the wound had increased in size and depth, there was no documentation of new interventions on this date.) -2/20/13 - Stage: "II", Size: 3.5 cm. Depth: blank. Response to Treatment: "Improved." Plan of Care Updated: blank. -2/27/13 - Stage: blank. Size: 3.0 x 2.5 cm. Depth: 0.2 cm. Response to Treatment: "Improved." Plan of Care Updated: "Cont(inue) tx (treatment). Healing. Bleeds (with) dressing (change)." -3/7/13 - Stage : "II". Size: 1.5 x 1.0 cm. Depth: 0.2 cm. Response to Treatment: "Improved." Plan of Care Updated: blank. -3/13/13 - Stage: "II". Size: 1.0 x 1.0 cm. Depth: 0.2 cm. Response to Treatment: "No Change." Plan of Care Updated: "Has a 0.3 (cm) round area white top of beefy area." -3/20/13 - Stage: "II". Size: 1.4 x 0.8 cm. Depth: blank. Response to Treatment: "Healed". Plan of Care Updated: "0.2 (cm) deep." -3/28/13 - Stage: "II". Size: 1.3 x 0.8 cm. Depth: 0.2 cm. Response to Treatment: "No Change." Plan of Care Updated: blank. -4/5/13 - Stage: "II". Size: 1.3 x 0.8 cm. Depth: 0.2 cm. Response to Treatment: "No Change." Plan of Care Updated: "appears smaller (and) less deep. (No complaints) of pain." -4/16/13 - Stage: "II". Size: 1.5 x 0.2 cm. Depth: 0.2 cm. Response to Treatment: "Improved." Plan of Care Updated: blank. -4/25/13 - Stage: "II". Size: 1.2 x 0.6 cm. Depth: 0.2 cm. Response to Treatment: "Improved." Plan of Care Updated: blank. -5/3/13 - Stage: "II". Size: 1.0 x 0.6 cm. Depth: 0.2 cm. Response to Treatment: blank. Plan of Care Updated: blank. -5/22/13 - Stage: "II". Size: 0.5 x 0.5 cm. Depth: 0.2 cm. Response to Treatment: "Improved." Plan of Care Updated: blank. -5/29/13. Stage: "II". Size: 0.4 x 0.3 cm. Depth: 0.1 cm. Response to Treatment: "Improved." Plan of Care Updated: "hard ridge around outside." -6/5/13 - Stage: blank. Size: 0.2 x 0.3 cm. Depth: 0.1 cm. Response to Treatment: "Improved." Plan of Care Updated: blank. -6/12/13 - Stage: "II". Size: 0.3 x 0.2 cm. Depth: 0.1 cm. Response to Treatment: "Healed." Plan of Care Updated: blank. -6/19/13 - Stage: "II". Size: 0.2 x 0.2 cm. Depth: 0.1 cm. Response to Treatment: blank. Plan of Care Update": blank. -6/26/13 - Stage: "II". Size: 0.3 cm. Depth: 0.1 cm. Response to Treatment: blank. Plan of Care Updated: blank. -7/7/13 - Stage: "II". Size: dry blister removed." Depth: blank. Response to Treatment: "Healed." Plan of Care Updated: "Continue skin prep to protect heel." -7/11/13 - Stage: blank. Size: 0.3 cm. Depth: 0. Response to Treatment: blank. Plan of Care Updated: blank. -7/19/13 - Stage: blank. Size: 0.3 cm. Depth: 0. Response to Treatment: blank. Plan of Care Updated: blank. -7/24/13 - Stage: blank. Size: 0.4 x 0.3 cm Depth: blank. Response to Treatment: blank. Plan of Care Updated: "(change) (treatment) to skin prep." -7/31/13 - Stage: blank. Size: 1 cm. Depth: blank. Response to Treatment: "Deteriorated." Plan of Care Updated: "scab bigger." -8/8/13 - Stage: blank. Size: 0.5 cm. Depth: 0. Response to Treatment: "Improved." Plan of Care Updated: blank. -8/22/13 - Stage: "II?". Size: 0.3 cm. Depth: "?". Response to Treatment: "Improved." Plan of Care Updated: blank. (NOTE: The Plan of Care Update section was blank 19 of 26 of these assessments.) (NOTE: Resident #1's care plan did not document to float her heels until 4/16/13, more than 3 months after the pressure ulcers to her heels were first noted.) c. (NOTE: For the purposes of clarity to the reader, Examples c. and d. will be designated as wound A (1) and A (2), respectively, even though facility wound documentation refers to both of the wounds in these examples as Wound A.) A separate Wound/Skin Record sheet for Resident #1 documented for Site A (1), onset date 3/9/13, a location of "left foot". A pre-printed diagram on the form had been marked to indicate the affected area was on the bottom of the resident's left foot, just below her little toe: -3/9/13 - Stage: "I". Size: 0.5 cm. Depth: 0.1 cm. "Response to Treatment": blank. "Plan of Care Updated': blank. -3/13/13 - Stage: "I". Size: 0.5 cm. Depth: 0.2 cm. "Response to Treatment": "No Change." "Plan of Care Updated": "(change treatment)." -3/20/13 - Stage: "I". Size: 0.2 cm. Depth: 0.2 cm. "Response to Treatment": "Improved." "Plan of Care Updated": blank. -3/21/13. Stage: "II". Size: .05 cm "round". Depth: 0.2 cm. "Response to Treatment": blank. "Plan of Care Updated": "Callous came off. Bleeding well. (No signs or symptoms) of infection." -3/28/13 - Stage: "II". Size: 0.5 cm "round". Depth: 0.2 cm "open". "Response to Treatment": "No Change". "Plan of Care Updated: blank. -4/5/13 - Stage "I". Size: 0.5 cm "round". Depth: 0.2 cm "open". "Response to Treatment": "No Change". "Plan of Care Updated": blank. -4/16/13 - Stage: "I". Size: 0.5 cm. Doth 0.2 cm. "Response to Treatment": blank. "Plan of Care Updated": blank.-4/25/13 - Stage: "0". Size: 1 cm "blood blister". Depth: blank. "Response to Treatment": blank. "Plan of Care Updated": "blood blister only." -5/3/13 - Healed. d. A separate Wound/Skin Record sheet for Resident #1 documented for Site A (2), onset date 4/16/13, for a location of, "(bottom of) (left) little toe" a 0.5 cm x 0.2 cm wound, as follows (NOTE: The diagram on the form indicating the location of this wound was the same as for the previous wound): -4/25/13 - Stage: "II". Size: "blister 1.0 (cm)". Depth: 3 cm. "Response to Treatment": blank. "Plan of Care Updated": blank. -5/1/13 - Healed. On 8/29/13 at 2:30 PM, LN #3, identified as the facility wound nurse, was asked about the areas on Resident #1's heels. *LN #3 stated the areas on Resident #1's heels were discovered on the morning of 1/8/13, when the resident was assisted to get up for the day. LN #3 stated the areas were identified as pressure ulcers, as they developed over a bony prominence. LN #3 stated the areas had not been noted prior to 1/8/13. *LN #3 stated since the facility had identified the resident as being at high risk for skin breakdown, she would have had either "blue boots" (padded boots) on, or staff would have used "green boots" (padded boots with a hard bottom) if the resident was walking. LN #3 stated she was not sure whether there were other measures in place, such as floating the resident's heels, positioning her from side to side, etc., before the areas on the heels were noted on 1/8/13. *When asked what the presumed cause of the pressure ulcers on Resident #1's heels was, LN #3 stated, "(Resident #1) is a really hard person. I would guess she wasn't being turned every 2 hours. She is very resistive, very fearful. Sometimes if you get down and talk directly into her face, she will calm down." LN #3 stated if Resident #1 had been resistive to being turned, " I would have expected them to at least try to turn her. And she had some shoes that were starting to rub, so after those areas opened we stopped using the shoes." *LN #3, when asked about staging the wounds on Resident #1's heels, stated initially the wounds were considered unstageable because they were blisters. LN #3 stated after the blisters opened, the areas were staged as Stage II pressure ulcers. *LN #3, when asked why the air mattress was not implemented until 2/7/13 when the wounds were discovered on 1/8/13 stated, "First we put her in the blue boots because the pressure was isolated to her heels. But the boots didn't work, so we got the air mattress." (NOTE: The blue boots were identified as an intervention already in place when the areas on Resident #1's heels initially developed.) *LN #3, when asked why the wound to the left heel was noted as healed on 3/20/13 and 6/12/13, stated, "The wound did not heal. I marked the wrong box (on the form). The wound continued all along." On 8/29/13 at 2:30 PM, LN #3 was asked about the areas to Resident #1's left foot, near her toe. LN #3 stated, "We don't really know what happened there. It was a little pin prick thing there, under the green boot." LN #3 initially stated the facility could not identify a pressure point associated with those areas. LN #3 was asked about if the blisters to Resident #1's left foot would be considered pressure ulcers. LN #3 stated, "Because she had the boot there, yeah, it was probably pressure." LN #3 was asked what the facility had identified as a solution to resolve the areas to Resident #1's left foot. LN #3 stated, "We discovered a little piece of the boot had a screw inside it. We removed that piece of the boot, and we haven't had any further problems since." On 8/29/13 at 6:15 PM, the Administrator and DNS were informed of the surveyor's findings. On 9/4/13 at 7:00 AM, the facility faxed additional information for this issue. However, the additional information did not resolve the concerns. 2. Resident #10 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #10 was discharged to home on 7/30/13. Resident #10's most recent admission MDS assessment, dated 7/22/13, documented in part: * Skin conditions - Moisture Associated Skin Damage (MASD); * Applications of ointments/medications other than to feet; and, * No healed or unhealed pressure ulcers. Resident #10's most recent CAA, dated 7/22/13, triggered Pressure Ulcer which documented in part: * CAA triggers due to ADL assistance is needed and resident tends to stay in bed frequently or sit in recliner; * Impact - Potential for loss of skin integrity due to pressure and urinary incontinence; * Strength - Able to make needs known when cued; and * Interventions - Assess skin with cares. Encourage mobility, keep skin clean and dry. Resident #10's July 2013 Care Plan documented in part: * Problem - At risk for skin breakdown related to poor intake, hydration, mobility, incontinence; * Interventions - Keep skin clean and dry, linen smooth and wrinkle free; pillow under buttocks while in recliner; resident uses a pressure reducing mattress on bed; remind/assist resident to toilet frequently, change soiled undergarments and clean skin; and barrier cream to peri area after incontinent episodes per MD orders. A Norton Plus Pressure Ulcer Scale, dated 7/16/13, documented a total score of 7 which indicates Resident #10 was at high risk for development of pressure ulcers. Resident #10's Nursing Admission Assessment, dated 7/16/13, documented skin conditions noted on admission. The assessment form included a diagram of the human body to locate and identify skin conditions. On the diagram a circle was made on the coccyx area with the label, "Red," which indicated Resident #10 had redness to the coccyx area. Resident #10's Nurse's Notes, dated 7/16/13 (day of admission) to 7/30/13 documented in part: * 7/16/13 - Slight redness on coccyx; * 7/17/13 - Skin intact; * 7/19/13 - Buttocks red, small blister in upper coccyx area noted, skin barrier cream applied; * 7/24/13 - Some incontinence excoriation noted to coccyx, barrier cream applied; * 7/26/13 - Resident reports buttocks are sore, encouraged staff to place a pillow under buttocks while in recliner for comfort and pain relief; Note: A pillow is not an effective device for reducing pressure as they typically bottom out. * 7/26/13 - Resident with contact [MEDICAL CONDITION] to coccyx; * 7/26/13 - Coccyx remains red with roughened skin over tail bone; * 7/30/13 - Some skin breakdown noted on buttocks, staff use barrier cream with cares; and, * 7/30/13 - Noted skin to buttocks reddened related to incontinence and resident sliding self in chair. Resident is able to off load and moves self in chair. Resident often incontinent of bowel and bladder, received frequent perineal care with barrier applications to protect skin. On 8/28/13 at 3:00 p.m., Resident #10's responsible party stated that Resident #10 was supposed to be turned every 2 hours, and went home with sores on bilateral buttocks. The responsible party stated the resident had to go to the "Wound clinic after discharge." and described the sores as "Apricot" size. The responsible party said the resident had "No sores on admit." Resident #10's responsible party stated on one occasion there was no barrier cream for the buttocks and it had to be requested. On 8/30/13 at 10:19 a.m., LN #3 was interviewed regarding Resident #10's skin breakdown to the coccyx area. The LN stated the resident came from the hospital with excoriated, sloughing skin breakdown on the coccyx. LN #3 added, "I know it got better. Then with loose stools it got red again." When asked what interventions were in place to prevent skin breakdown to the coccyx the LN stated, "Trying to keep him dry in toileting. (The resident was) trying to toilet self but didn't make it." LN #3 said the resident would sit in the recliner frequently and was, "Encouraged to go back to bed for at least an hour." When asked if Resident #10 was on a scheduled turning program the LN stated she didn't know about during the day, but they were "Turning (him) at least twice at night." LN #3 was asked what Resident #10's coccyx looked like on the day of discharge. The LN stated, "I did see him that morning. I want to say it was just red because (staff's name) stated that." When asked if the resident had a pressure ulcer to the coccyx the LN responded, "No." Note: LN #3 stated Resident #10 was admitted from the hospital with excoriated, sloughing skin breakdown on the coccyx. However, the admission skin assessment documented the coccyx was red, but the facility did not measure the redness, did not monitor the area daily, and had no care plan for repositioning at prescribed intervals. Additionally, there was no documentation that distiguished the differentiation between moisture associated skin damage versus a pressure ulcer, and inconsistent documentation regarding the location of skin breakdown. On 8/30/13 at 11:40 a.m., the Administrator and DON were informed of the skin breakdown issue. However, no further information or documentation was provided that resolved the issue.