Every finding on record at Orchard View Post Acute

Based on observations, interviews, and policy review, the facility failed to maintain sanitation in one of one dining room area by allowing a dog to wander the dining area and into two of eight residents' rooms during a meal. This failure had the potential to expose the residents to harmful pathogens and infections.Findings include:Review of the 2022 Food Code by the U.S. Food and Drug Administration, located at https://www.fda.gov/food/fda-food-code/food-code-2022, Chapter 6-501.115, indicated that pets in nursing homes were allowed in the common areas except during mealtimes.Review of the facility's undated policy titled, Pets in the Building indicated that staff must keep pets out of the dining area during mealtimes.During a meal observation on 08/12/25 at 12:43 PM, a dog was observed wandering in and out of the dining area during the lunch meal service. The dog was observed to go up to several different residents and sit by them begging for food. Residents were observed to tell the dog no, and the dog would go to a different resident. The dog was observed to wander in and out of room [ROOM NUMBER] and 314 several times while the residents in those rooms were eating their meals.During an interview on 08/13/25 at 11:43 AM, the Dietary Manager (DM) stated that dogs did not belong in the dining room, and their owner should be monitoring them.During an interview on 08/13/25 at 2:41 PM, the Director of Nursing (DON) stated that dogs did not belong in the dining room, and the owners have been educated to keep better track of them and keep them out of the dining area.

Based on record review, interview, and facility policy review, the facility failed to protect the residents right to be free from physical abuse by other residents for two out of nine residents (Resident (R) 32, and R61) reviewed for abuse of 25 sample residents. These failures had the potential to cause physical harm or psychosocial distress.Findings include:Review of the facility's policy titled, Abuse screening, training, identification, investigation, reporting and protection - Idaho, dated February 2019, revealed It is the policy of this center to.Protect our residents from abuse.Abuse is defined as.the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.Instances of abuse of all residents, irrespective of any mental, physical condition, cause physical harm, pain or mental anguish. 1. a. Review of R23's EMR under the Profile tab revealed he was admitted to the facility on [DATE] and had diagnoses of anxiety, personality and behavioral disorder, schizoaffective disorder, mood disorder, and restlessness/agitation.Review of R23's annual MDS with an ARD of 06/04/25 and located under the MDS tab of the EMR, revealed a BIMS score of two out of 15 which indicated R23 was severely cognitively impaired. He exhibited minor mood symptoms and no behavioral symptoms.b. Review of R32's admission Record located under the Profile tab of the EMR, revealed he was admitted to the facility on [DATE] and had diagnoses including intracerebral hemorrhage and depression.Review of R32's quarterly MDS with an ARD of 05/15/25 and located under the MDS tab of the EMR, revealed a BIMS score of nine out of 15 which indicated R32 was moderately cognitively impaired. He exhibited moderate mood symptoms but did not exhibit behavioral symptoms.Review of R23's Behavior Note, dated 03/09/25 and located under the Progress Notes tab of the EMR, revealed Resident walk [sic] up to the nurse station, no word said other than breathing heavily then LN saw both arms up and reaching for LN neck, LN backed up as this resident was grabbing holding on and hands were around LN neck, this LN had to put foot up against this resident's abdomen to stop this resident though this resident was too strong. Another resident [R32] was in the hallway that saw and witnessed the entire as this resident continue [sic] to grab, hit, push, and attempt to cause serious bodily harm. Other resident in the hallway observed the incident and help [sic] intervene. The other resident help [sic] pull this resident off LN. Then this resident [R23] went after the other resident [R32] and grabbed his arm attempting to cause bodily harm to this resident. On-call nurse notified, and administrative staff notified. Review of the facility's investigation packet for the above incident, dated 03/14/25 and provided on paper, revealed the incident occurred on 03/09/25 at 1:30 PM. R23 began choking RN2 and R32 tried to intervene, at which time R23 grabbed R32's arm and twisted it. Interviews with staff revealed RN2 was directly involved in the incident and witnessed R23 grab and twist R32's arm. Interview with R32 revealed he stated R23 grabbed his arm, and assessment revealed a bruise to R32's right arm. The facility's investigation substantiated resident-to-resident abuse occurred, as it was witnessed by staff and residents. R32 only received minor bruising and did not exhibit signs or symptoms of psychosocial distress.During an interview on 08/13/25 at 2:17 PM, the Director of Nursing (DON) stated on 03/09/25, R23 began choking RN2 without any warning. She stated R32 attempted to intervene when R23 turned his attention to R32 and grabbed his arm. The DON stated this incident of resident-to-resident abuse was substantiated because the incident was witnessed and R23 assaulted R32. The DON stated the police department was contacted in this situation, but no citations were made and R23 was sent to the emergency room for psychiatric evaluation.2. a. Review of R61's admission Record located under the Profile tab of the EMR, revealed he was admitted to the facility on [DATE] and had diagnoses including weakness and limitation of activities due to disability, subdural hemorrhage, and depression.Review of R61's quarterly MDS with an ARD of 05/18/25 and located under the MDS tab of the EMR, revealed a BIMS score of 12 out of 15 which indicated R61 was moderately cognitively impaired. He exhibited minor mood symptoms and no behavioral symptoms. b. Review of R32's admission Record located under the Profile tab of the EMR, revealed he was admitted to the facility on [DATE] and had diagnoses including intracerebral hemorrhage and depression.Review of R32's quarterly MDS with an ARD of 05/15/25 and located under the MDS tab of the EMR, revealed a BIMS score of nine out of 15 which indicated R32 was moderately cognitively impaired. He exhibited moderate mood symptoms but did not exhibit behavioral symptoms.Review of R61's Alert Charting, dated 05/09/25 and located under the Progress Notes tab of the EMR, revealed At 1020 this LN heard yelling coming from down the hallway, I went into room.and observed [R32] standing up over roommate [R61] who was sitting on his bed. [R32] was yelling at roommate with his hands up making fists. I asked what was going on and [R32] swung and hits [sic] roommate with his Rt [right] hand on [R61] Lt [left] side of his face.Review of the facility's investigation packet for the above incident, dated 05/16/25 and provided on paper, revealed the incident occurred on 05/09/25 at 10:10 AM. RN4 observed R32 standing over R61, who was sitting on his bed. R32 was yelling and making fists, and he swung and hit R61 on the face. Police were contacted and R32 was cited with battery. Interview with RN4 confirmed R32 punched R61 in the face. Interview with R32 revealed he admitted to hitting R61 and stated R61 had kicked him in the shin. Interview with R61 revealed he was hit in the face by R32 and denied kicking R32. R32 had redness to his shin. R61 received minor redness and swelling and did not exhibit signs or symptoms of psychosocial distress.During an interview on 08/13/25 at 2:17 PM, the DON stated on 05/09/25, an altercation occurred between R32 and R61, who were roommates. She stated R32 reported R61 kicked him in the leg; however, R61 denied this. R32 was witnessed to punch R61 in the face and R32 denied kicking R61. The DON stated the police were called and only R32 was issued a citation, as R61 denied kicking R32. However, R32's shin had redness upon assessment. The DON stated this was a substantiated case of resident-to-resident abuse.

Based on interview and record review the facility did not ensure an alleged violation involving abuse was reported immediately to the Director of Nursing (DON) and to other officials in accordance with state law through established procedures for two of nine residents (Resident (R) 6 and R69) reviewed for abuse of 25 sample residents. This failure decreased the facility's potential to protect the residents from a possible allegation of abuse and ensure a safe environment during the investigation.Findings include:Review of the facility's policy titled, Abuse screening, training, identification, investigation, reporting and protection-Idaho, dated 02/19, indicated that all employees were mandatory reporters and any suspicion of a crime including assault must be reported if there was an injury or within 24 hours if there was no bodily injury.Review of the facility's policy titled, Grievance, dated 03/19, indicated that alleged violations involving abuse should be reported immediately as required by state law and facility policy. 1. Review of R6's Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnosis that include heart failure, respiratory failure, type II diabetes, kidney failure, and hypertension.Review of R6's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R6 was cognitively intact.During an interview on [DATE] at 11:35 AM, R6 stated that on [DATE] of this year, somebody came into her room while she was sleeping and cut her hair off. R6 stated that she told the nurse, but nobody had done anything about it.During an interview on [DATE] at 12:42 PM, the Administrator stated that R6 did report the incident and filed a grievance report. The Administrator stated that R6 reported that two residents had entered her room while she was asleep and cut her hair. The Administrator stated that the Director of Nursing (DON) had conducted the investigation and had determined during the investigation that R6's hairclip which she never removed from her hair had somehow broken her hair off and no residents were involved. A review of the grievance report, provided by the facility, revealed that the report was filed on [DATE] indicating that the incident happened on [DATE] and reported as two residents came into R6's room and cut her hair off while she was asleep.During an interview on [DATE] at 2:44 PM the DON stated that the grievance was given to her by the Social Worker and she immediately investigated it. The DON stated that the incident was not reported because when she talked with R6 she told her that nobody came into her room and cut her hair. The DON stated that upon inspection of R6's hair they did not find any cutting marks and the hair looked broken and R6 could not find the hairclip she always wore.During an interview on [DATE] at 2:05 PM the Social Service Director (SSD) stated as soon as she received the grievance, she alerted the DON and went and talked with R6. The SSW stated R6 told her no one was in her room, so she felt there was no need to report the incident to the state agency. The SSW agreed that the way the incident was reported, it should have been reported before they determined there was no abuse or an assault did not happen. The SSW stated staff should know how to report these allegations and should not have filed a grievance but reported it as an allegation of an assault.During an interview on [DATE] at 4:06 PM, Licensed Practical Nurse (LPN) 1 stated R6 reported to her that two residents came into her room and cut her hair off, but she didn't notice it for two days. LPN1 stated she looked for signs of her hair being cut but couldn't find any hair. LPN1 stated she noted R6 had a pair of scissors on her nightstand but could not determine if her hair was cut. LPN1 stated that they did not have any residents who wandered and no reported residents going into other resident rooms. LPN1 state she helped R6 fill out a grievance form because she was told that was what needed to be done. LPN1 could not recall who told her that a grievance form should be filled out instead of an abuse report. 2. Review of R69's Profile tab of the EMR revealed she was admitted to the facility on [DATE] with diagnosis that include type II diabetes, overactive bladder, schizophrenia disorder, anxiety, bi-polar disorder, and cognitive communication deficit. R69 expired in the facility on [DATE].Review of R69's quarterly MDS with an ARD of [DATE] and located in the MDS tab of the EMR, revealed a BIMS score of 15 out of 15 which indicated R69 was cognitively intact.A review of a Facility Reported Incident (FRI), dated [DATE] and provided by the facility, revealed R69 reported an allegation of sexual abuse when she awoke to a Certified Nursing Assistant (CNA) checking her brief. R69 became upset and asked the CNA to get the supervisor on duty. R69 reported she felt she was being sexually assaulted when the CNA was checking her brief. The supervisor reassured R69 that the CNA was checking her brief and calmed her down. The report indicated that the incident occurred at 1:05 AM and was not reported to the DON until 8:05 AM. A full investigation was then initiated by the DON and reported to the appropriate agencies. During an interview on [DATE] at 1:37 PM the DON stated that she was notified of the incident when she was getting to work by the nurse on duty. The DON was aware the nurse should have immediately contacted her and in-serviced the nurse on reporting appropriately. The DON stated she immediately reported the incident and did a full investigation. The DON stated that the CNA was suspended during the investigation and was re-instated when the allegation was unsubstantiated but did not work with the resident again. During an interview on [DATE] at 9:27 PM, Registered Nurse (RN) 3 stated she was called into the R69's room by CNA5. RN3 stated R69 was visibly upset and told her CNA5 had sexually molested her. RN3 stated she explained to R69 that the CNA was checking her brief as she was assigned to do. RN3 stated that R69 stated she was not fully awake and was startled by the incident. RN3 stated she assured R69 that CNA5 would not come into the room and that she would be the only staff to assist her the rest of the night. RN3 stated that R69 calmed down and went back to sleep. RN3 stated she did not send CNA5 home and did not immediately report the incident to the DON.

Based on record review, staff interview, and policy review, facility staff failed to protect one of nine residents (Resident (R) 69) reviewed for abuse from further abuse by not immediately removing a staff from the facility who was accused of sexual abuse of 25 sample residents. This failure decreased the facility's potential to protect the residents and ensure a safe environment during the investigation.Findings include:Review of the facility's policy titled, Abuse screening, training, identification, investigation, reporting, and protection-Idaho, dated 02/19, indicated that any staff member involved will be removed from their duties and sent home while a thorough investigation was conducted. Review of R69's Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnosis that include type II diabetes, overactive bladder, schizophrenia disorder, anxiety, bipolar disorder, and cognitive communication deficit. R69 expired in the facility on [DATE].Review of R69's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R69 was cognitively intact.A review of a Facility Reported Incident (FRI), dated [DATE] and provided by the facility, revealed R69 reported an allegation of sexual abuse when she awoke to a Certified Nursing Assistant (CNA) checking her brief. R69 became upset and asked the CNA to get the supervisor on duty. R69 reported she felt she was being sexually assaulted when the CNA was checking her brief. The supervisor reassured R69 that the CNA was checking her brief and calmed her down. The report indicated that the incident occurred at 1:05 AM and was not reported to the Director of Nursing (DON) until 8:05 AM. A full investigation was then initiated by the DON.During an interview on [DATE] at 1:37 PM, the DON stated that she was not notified of the incident until she arrived at work by the nurse on duty. The DON stated she did a full investigation. The DON stated that the CNA was not suspended until she received the report at 8:00 AM but was re-instated when the allegation was unsubstantiated and did not work with the resident again. During an interview on [DATE] at 9:27 PM, Registered Nurse (RN) 3 stated she was called into the R69's room by CNA5. RN3 stated R69 was visibly upset and told her CNA5 had sexually molested her. RN3 stated she explained to R69 that the CNA5 was checking her brief as she assigned to do. RN3 stated that R69 stated she was not fully awake and was startled by the incident. RN3 stated she assured R69 that CNA5 would not come into the room and that she would be the only staff to assist her the rest of the night. RN3 stated that R69 calmed down and went back to sleep. RN3 stated she did not send CNA5 home at the time of the incident and did not immediately report the incident to DON because she told CNA5 not to go back in the room and took over the care of R69.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the medication usage of three (Resident (R) 4, R61, and R34) of 25 residents reviewed in the sample. These failures created potential for an incomplete or ineffective plan of care related to medication use and side effect monitoring.Findings include:1. Review of R4's admission Record located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] with diagnoses including type two diabetes with hyperglycemia.Review of R4's quarterly MDS with an Assessment Reference Date (ARD) of 06/20/25 and located under the MDS tab of the EMR, revealed she used hypoglycemic medication and used insulin one day of the previous seven days.Review of R4's Medication Administration Record (MAR), dated June 2025 and located under the Reports tab of the EMR, revealed an order, which originated on 05/27/25, for Ozempic (a hypoglycemic medication that is not an insulin), one time a week for diabetes management. There were no orders for insulin on the MAR.During an interview on 08/14/25 at 1:25 PM, the MDS Coordinator (MDSC) stated R4 was using Ozempic, which she mistakenly believed was an insulin. After further research, the MDSC agreed R4 was receiving hypoglycemic medication but was not receiving insulin, and this was incorrect on the MDS.2. Review of R61's admission Record located under the Profile tab of the EMR, revealed he was admitted to the facility on [DATE] with diagnoses including type two diabetes.Review of R61's quarterly MDS with an ARD of 05/18/25 and located under the MDS tab of the EMR, revealed he used hypoglycemic medication and used insulin one day of the previous seven days.Review of R61's MAR, dated May 2025 and located under the Reports tab of the EMR, revealed an order, which originated on 04/04/25, for Ozempic one time a week for diabetes management. There were no orders for insulin on the MAR.During an interview on 08/14/25 at 1:25 PM, the MDSC stated R61 was using Ozempic, which she mistakenly believed was an insulin. After further research, the MDSC agreed R61 was receiving hypoglycemic medication but was not receiving insulin, and this was incorrect on the MDS.3. Review of R34's admission Record located under the Profile tab of the EMR, revealed he was admitted to the facility on [DATE] with diagnoses including history of stroke.Review of R34's quarterly MDS with an ARD of 06/26/25 and located under the MDS tab of the EMR, revealed he used anticoagulant medication.Review of R34's MAR, dated June 2025 and located under the Reports tab of the EMR, revealed an order, which originated on 03/20/25, for clopidogrel bisulfate (an antiplatelet medication that is not anticoagulant) for stroke prevention. There were no orders for an anticoagulant on the MAR.During an interview on 08/14/25 at 1:25 PM, the MDSC stated R34 was using an antiplatelet medication and not an anticoagulant; this was a data entry error on the MDS.During an interview on 08/14/2025 at 1:47 PM, the Administrator stated the facility did not have a policy addressing MDS accuracy and followed the guidance in the RAI [Resident Assessment Instrument] Manual.Review of the Centers for Medicare & Medicaid Services (CMS) RAI Manual, dated October 2024 and located at https://www.cms.gov/files/document/finalmds-30-rai-manual-v1191october2024.pdf, revealed, Insulin.Steps for Assessment 1. Review the resident's medication administration records for the 7-day look-back period.2. Determine if the resident received insulin injections during the look-back period.4. Count the number of days insulin injections were received.Coding Instructions.Enter.the number of days during the 7-day look-back period.that insulin injections were received.Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period.Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel as.Anticoagulant.

Based on interview, record review, and policy review, the facility failed to ensure a newly admitted resident had a baseline care plan documented within 48 hours of admission for one of four residents (Resident (R) 70) reviewed for baseline care plan of 10 newly admitted residents. As a result of this deficient practice the residents had the potential for care needed not being provided during the initial days of admission to the facility.Findings included:Review of the facility's policy titled, Care Plans-Baseline, revised 05/24, revealed A baseline plan of care should be developed for each resident within forty-eight (48) hours of admission. The baseline care plan should include instructions needed to provide effective, person-centered care of the resident, which may include the following: a. Initial goals based on admission orders and discussion with the resident/representative. b. Physician orders. c. Dietary orders. d. Therapy services. e. Social services.Review of R70's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 08/06/25 with medical diagnoses that included encephalopathy and aftercare provided after total joint replacement.Review of R70's EMR revealed the document for a baseline care plan had not been initiated or completed.During an interview on 08/12/25 at 1:15 PM, the Resident Care Manager (RCM) 1 reviewed the EMR for R70 and confirmed the EMR lacked completion of the baseline care plan by the admitting nurse, and it should have been completed.During an interview on 08/12/25 at 2:39 PM, the Director of Nursing (DON) confirmed there should be a baseline care plan for all new admission residents within 48 hours of admission.

Based on record review, interview, and policy review, the facility failed to develop a comprehensive Care Plan for one of 25 sample residents (Resident (R) 4) that addressed psychiatric diagnoses and needs. This placed R4 at risk for unmet psychosocial and behavioral care needs and the inability to meet their maximum practicable level of functioning.Findings include:Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated March 2022, revealed The comprehensive, person-centered care plan.describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including.any specialized services to be provided as a result of PASARR [preadmission screen and resident review] recommendations.Review of R4's admission Record located under the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE] and had diagnoses including bipolar disorder, major depression, insomnia, suicidal ideation, and post-traumatic stress disorder (PTSD). Review of R4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/20/25 and located under the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS)score of 14 out of 15 indicating intact cognition. She exhibited only minor mood symptoms and no behavioral symptoms. R4 received antianxiety and antidepressant medications.Review of R4's Pre-admission Screen and Resident Review (PASARR) Level II Evaluation, dated 04/26/23 and located under the Documents tab of the EMR, revealed, Supporting documents identify diagnoses of bipolar disorder, major depressive disorder, anxiety disorder, posttraumatic stress disorder, and borderline personality disorder. Remote history of suicidal ideation with inpatient hospitalization 6/2022. Provider note of 3/29/2023 references restarting counseling. [R4] may benefit from an evaluation for specialized services.Review of R4's Care Plan, dated 01/13/25 and located under the Care Plan tab of the EMR, revealed it did not address her diagnoses of post-traumatic stress disorder, depression, or bipolar disorder. During an interview on 08/14/25 at 1:45 PM, the Social Services Director (SSD) stated R4 was receiving medication for depression and anxiety, received daily visits by the SSD, and received counseling services. The SSD also stated R4 was followed by a psychiatrist and had a diagnosis of PTSD. The SSD stated the only trigger she was aware of for R4's PTSD/anxiety was using the telephone. The SSD stated her diagnoses, and potential PTSD should have been included in the Care Plan in order to develop appropriate interventions.

Based on observations, interviews, record review, and policy review, the facility failed to ensure the indwelling urinary catheter tubing and collection bag were not in contact with the floor for one of three residents (Resident (R) 54) reviewed for catheters and urinary tract infection of 25 sample residents. This failure placed the residents at risk for transmission of infection to the urinary tract.Findings include:Review of the facility's policy titled, Catheter Care, Urinary, dated 08/22, indicated that to prevent urinary catheter-associated complications, staff should be sure to keep the catheter tubing and collection bag off the ground. Review of the Profile tab in R54's electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including depression, heart failure, neurogenic bladder, adult failure to thrive, overactive bladder, and history of urinary tract infections.Review of R54's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/25/25 and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R54 was cognitively intact. She used an indwelling urinary catheter.During an observation on 08/11/25 from 2:06 PM to 3:12 PM, R54 was sitting in her wheelchair in the activity area. R54's catheter tubing was observed dragging on the floor as several staff passed by. During an interview on 08/11/25 at 3:12 PM, Certified Nursing Assistant (CNA) 6 stated that R54's catheter tubing was usually checked several times a day. CNA6 stated she did not notice the tubing was on floor and it did not belong there. CNA6 stated that the catheter privacy bag seemed small, and the tubing tended to come out of the bag. During an interview on 08/13/25 at 2:34 PM, the Director of Nursing (DON) stated that catheter tubing and placement was checked every shift and would expect staff to check often during the day to ensure the tubing was not dragging on the ground.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications and medical supplies available for residents were not expired. This was true for 1 of 2 medication storage rooms observed. This failure created the potential for residents to receive expired medications or medical supplies with decreased efficacy. Findings include: The facility's Medication Storage: Storage of Medication policy, initiated January 2023, documented, outdated medications are immediately removed from stock and disposed of according to procedures for medication disposal. On 10/10/24 at 8:35 AM, one of the facility's medication storage rooms was inspected with LPN #1 present. The following medications were observed to be expired: -One bottle of Deep-Sea Nasal Spray, expired 1/24. -Two bottles of Allergy Relief (fexofenadine hydrochloride) 180 mg tablets, expired 8/24. -Two bottles of Bisacodyl 5 mg tablets, expired 9/24. -One open box of Nicotine patches 21 mg, expired 7/24. -Five bottles of Niacin 100 mg, expired 8/24. -58 single use packets of A & D ointment, expired 5/24. -Two boxes with 100 each, Cotton tipped applicators, individually wrapped, expired 9/22. -One box of 200 Alcohol wipes, individually wrapped, expired 1/24. On 10/10/24 at 8:44 AM, LPN #1 stated it was all of the nurse's responsibility to check the dates on these medications and medical supplies and dispose of the expired ones. On 10/11/24 at 10:00 AM, the DON confirmed the expired medications and medical supplies should have been removed by the nursing staff.

Based on observation, interview, and facility policy review, it was determined the facility failed to label, date, and/or cover food stored in kitchen refrigeration units and dry storage areas. The facility also failed to discard food with expired use by dates and ensure a scoop was not stored in a container of brown sugar. This failure had the potential to create an environment for food-borne illnesses which could affect residents who consumed food prepared from the facility's kitchen. Findings include: The facility's policy titled, Food Receiving and Storage, dated ,d+[DATE], documented food would be received and stored in a manner that complies with safe food handling practices, dry foods that are stored in a bin will be removed from the original packaging, labeled and dated with the use by date, and all foods stored in the refrigerator or freezer will be covered, labeled, and dated with the use by date. The facility's undated policy titled, Use by Dates, documented all open food items in the refrigerator needed use by dates. The facility will label, date, and monitor refrigerated food so it is used by its use by date, frozen (where applicable), or discarded, and condiments should be opened and used for 6 months before they are discarded. 1. On [DATE] from 2:00 PM to 2:50 PM, [NAME] #1 was present during the initial kitchen observation when the following concerns were identified: a. Observation of food stored in the kitchen's Cooks reach-in refrigerator revealed one opened and undated package of turkey slices, one opened and undated five pound package of mild cheddar cheese, one opened and undated package of parmigiana cheese, one opened and undated 138-ounce container of Dijon wine mustard, one opened and undated gallon container of honey mustard dressing, one opened and undated gallon container of pickle relish, three undated hard boiled eggs, five undated individual serving containers of cottage cheese, eight undated individual serving containers of ranch dressing, three undated packages of thawed hot dog buns, one undated package of thawed hoagie buns, two undated packages of thawed bread sticks, and one undated 20-ounce package of thawed wheat bread. Also, stored in this reach-in refrigerator was one opened 138-ounce container Dijon wine mustard with a handwritten date of ,d+[DATE] on its lid and a small food preparation pan which contained an unidentified food that was not labeled or dated. b. Observation of food stored in the kitchen's Aides reach-in refrigerator revealed two opened and undated 46-ounce containers of thickened lemon-flavored water, one opened and undated 46-ounce container of thickened apple juice, one undated dish of pureed peaches, and one opened and undated 16-ounce container of whipped topping. c. Observation of food stored in the kitchen's walk-in refrigerator revealed an opened 48-ounce box of Neufchatel cheese which had an expired use by date of [DATE], seven undated 12-ounce packages of thawed English muffins, 11 undated 20-ounce packages of thawed white bread, and seven undated packages of thawed hot dog buns. d. Observation of food stored in the kitchen's dry storage room revealed one opened 10-pound package of dry spaghetti noodles which was not closed and was unprotected from contamination, one opened 25-pound bag of all-purpose flour (stored in its original bag) that was not closed and was unprotected from contamination, and one opened twenty-five-pound box of dry food thickener that was not closed and was unprotected from contamination. e. Observation of food stored in kitchen food preparation areas revealed one large unlabeled and undated container which contained brown sugar that had a scoop stored inside the container with the scoop's handle embedded in the brown sugar, and one opened six-pound container of rainbow sprinkles that was not closed and was unprotected from contamination. On [DATE] during the initial kitchen observation, [NAME] #1 confirmed all of the observed food storage concerns. [NAME] #1 stated the kitchen staff had been instructed to always label, date, and cover all opened and stored food and not to store scoops in dry food goods. [NAME] #1 stated the date of ,d+[DATE] written on the 138- ounce container of Dijon wine mustard stored in the Cooks reach-in refrigerator, indicated it was opened by staff on [DATE] and it should have been discarded after 6 months and needed to be discarded immediately. On [DATE] at 8:55 AM, the DM stated food should be labeled, dated, and covered when opened and stored. The DM explained if food packaging was opened and the food was not dated, or the food had an expired use by date, it should be discarded. On [DATE] at 11:25 AM, the DM stated staff should date bread products when thawed and bread products should be discarded if not used within seven days of this thaw date per the bread vendor's storage instructions.

Based on observation, interview, record review, facility menu review, and policy review, it was determined the facility failed to ensure menus were followed as planned for 3 of 3 residents (Resident #16, #25, and #36) reviewed for this concern. This failure had the potential to cause nutritional needs to go unmet for residents who consumed food prepared from the facility's kitchen. Findings include: The facility's policy titled Menus, revised 10/2008, documented, menus will be prepared in advance, meet the nutritional needs of residents, and be followed. 1. The facility's menu for Sunday 10/6/24 documented sweet and sour chicken with Asian stir-fry was planned to be served for the evening meal. Resident #25's MDS assessment on 8/20/24 documented he was cognitively intact. During an interview on 10/8/24 at 2:55 PM, Resident #25 stated on Sunday, 10/6/24, the menu was not served as planned. He stated this tends to happen on the weekends or Monday's because the kitchen did not have the ingredients required to prepare what was on the menu. On 10/9/24 at 12:52 PM, the DM stated he was not always able to order all ingredients needed for the cooks to follow the standardized recipes of food on the planned menu because he had to pare down his food orders to ensure food costs were within budget as directed by the facility's prior Administrator. During an interview on 10/10/24 at 4:00 PM, the DM confirmed the stir-fry was not served on Sunday 10/6/24, as planned on the menu because the kitchen did not have enough of the ingredients required to prepare it. On 10/11/24 at 10:00 AM, the facility's Interim Administrator stated he expected the residents would be served food at meals that they liked and enjoyed. The Interim Administrator stated there should be no budgetary restrictions on the kitchen staff purchasing the food needed to serve the facility's menu as planned. 2. On 10/8/24 the facility's breakfast menu documented 1 cup of milk was to be served with the meal. Resident #16's MDS assessment on 9/5/24 documented she was moderately cognitively impaired. Resident #16's EMAR for October 2024 documented she was prescribed to receive a regular diet. On 10/8/24 at 8:20 AM, a staff was observed serving Resident #16 her breakfast meal tray in the main dining room. The staff was observed telling Resident #16 and other residents at the table that the kitchen was out of milk. Resident #16 was observed to be served dry cereal with her breakfast. On 10/8/24 at 8:30 AM, [NAME] #2 stated they ran out of milk during the breakfast meal service and a dietary employee left to go to the store to purchase milk. [NAME] #2 added she was informed they received only 2 gallons of milk in the food delivery on 10/7/24. On 10/8/24 at 8:35 AM, Resident #16 was observed in the dining room eating her cereal. The resident's cereal bowl was observed to have a small amount of milk at the bottom. Resident #16 stated LPN #1 brought milk in her lunch and shared her milk with Resident #16 and 4 other residents who did not receive milk with their dry cereal. On 10/8/24 at 8:50 AM, the Administrator stated he was unaware the kitchen only received 2 gallons of milk with their delivery on 10/7/24 or they had run out of milk during breakfast service. The Administrator stated the kitchen staff should have let him know so he could ensure there was milk for breakfast. On 10/8/24 at 8:55 AM, the DM confirmed the kitchen ran out of milk during breakfast service. The DM stated he was unaware they had only received 2 gallons of milk with their food delivery on 10/7/24 until about 20 minutes before breakfast service began. He stated they ordered and expected to receive 20 gallons of milk on 10/7/24 and did not know why their order was short. The DM stated the staff who informed him of the delivery shortage should have informed himself and the Administrator immediately so milk could be purchased and breakfast could be served as planned. 3. The facility's menu for breakfast on 10/9/24 documented residents' who receive regular diets should be served two pancakes with their meal. On 9/16/24, Resident #36 was assessed to have severe cognitive impairment. Resident #36's EMAR for October 2024 documented a physician order for him to receive a regular diet. On 10/9/24 at 8:33 AM, Resident #26 was observed eating breakfast in the main dining room. The meal slip served on his tray documented he was to receive a regular diet. Resident #36 was observed to have been served one pancake. Resident #36 stated he got one pancake and wanted another because he was still hungry. On 10/9/24 at 8:40 AM, the Administrator confirmed Resident #36 had been served one pancake and should have been served two pancakes. On 10/9/24 at 8:50 AM, the DM confirmed Resident #36 was prescribed a regular diet and his breakfast was not served as planned. The DM specified Resident #36 should have been served two pancakes.

Based on observation, interview, test tray review, record review, review of Resident Council Meeting Minutes, and facility policy review, it was determined the facility failed to serve food that was palatable for 7 of 7 residents (Residents' #10, #16, #17, #20, #24, #25, and #26) reviewed for food palatability. This failure created the potential to cause unmet nutritional needs for residents who consumed food prepared from the facility's kitchen. Findings include: The facility's policy titled, Food Preparation, dated 9/27/16, documented, food is stored and prepared by methods that conserve nutritive value, flavor, and appearance to the extent possible and food is prepared according to standardized, yield adjusted recipes by trained staff in order to produce a palatable and attractive meal. 1. On 8/20/24 Resident #25 was assessed to be cognitively intact. On 10/7/24 at 3:40 PM, Resident #25 stated the food served at the facility could be improved and specified the food served at meals did not always taste good and was not always seasoned. 2. Resident #20 was assessed on 10/1/24 to be cognitively intact. On 10/7/24 at 4:04 PM, Resident #20 stated the food served at the facility could be better and specified the food served at meals did not always taste good because it was not seasoned, and the meat was tough. 3. On 7/7/24, Resident #10 was assessed to be cognitively intact. On 10/7/24 at 4:07 PM, Resident #10 stated the food quality at the facility had gone downhill, was not prepared correctly, and did not taste good. Resident #10 stated the fancier the name of the food, the less edible the food was, and the food was lukewarm when served at meals. 4. On 9/5/24 Resident #16 was assessed to be moderately cognitively impaired. On 10/7/24 at 4:15 PM, Resident #16 stated the food served at the facility did not taste good because it was not seasoned and was not always hot when served. 5. Resident #24 was assessed on 7/16/24 to be cognitively intact. On 10/8/24 at 3:45 PM, Resident #24 stated he was not satisfied with the food served at the facility. Resident #24 specified that he would find better food if he went dumpster diving. 6. On 8/13/24, Resident #17 was assessed to be cognitively intact. On 10/8/24 at 3:30 PM, Resident #17 stated the food at the facility was inedible, and she had family bring her food from the outside to eat. 7. On 9/3/24, Resident #26 was assessed to be cognitively intact. On 10/8/24 at 10:01 AM, Resident #26 stated the food served at the facility was terrible. Resident #26 stated she had a family member bring her alternatives to eat that were palatable. 8. Review of Resident Council Meeting Minutes, from 04/25/24 to 09/26/24 documented the following resident concerns regarding food palatability: On 4/25/24, one resident stated, Vegetables were overcooked, one resident stated, Poor food quality, and one resident stated, We always get raw meat, especially on evenings and weekends. On 6/26/24, three residents stated, Meats were overcooked and tough. On 8/29/24, revealed one resident stated, Hamburgers were burnt, three residents stated, Meat was dry, and two residents stated, chicken was not cooked. On 10/9/24, the kitchen staff were observed plating meals. At 12:14 PM the food temperatures on a test tray were appropriately greater than 135 degrees Fahrenheit (F), the tray was placed in an enclosed cart with no heating element. The meal cart with the test tray was observed to arrive on the 300-hallway at 12:17 PM. Staff were observed to complete serving the residents meal trays at 12:30 PM in the main dining room. At this time, the foods and beverages on the test tray were sampled in the presence of the facility's Dietary Manager (DM). The green beans served on the test tray tasted bland and lacked seasoning. The DM tasted the green beans and confirmed they tasted bland and lacked seasoning. On 10/9/24 at 12:50 PM, [NAME] #2 stated they used standardized recipes for the menu items and specified for the green beans the recipe directed the use of olive oil and a salt-free seasoning blend. [NAME] #2 stated when she prepared the green beans she did not use olive oil and added a small amount of butter and did not use the salt-free seasoning blend because it was unavailable. On 10/9/24 at 12:52 PM, the DM confirmed the salt-free seasoning blend was not available. The DM stated he was instructed by the previous Administrator to pare down his food orders and was unable to purchase all of the ingredients required for the recipes to manage the budget. On 10/11/24 at 10:00 AM, the current Administrator stated the residents would be served food they liked and enjoyed and there should be no budgetary restrictions on purchasing ingredients necessary to serve the facility's menu as planned.

Based on observation, interview, record review, review of Resident Council Minutes, and facility policy review, it was determined the facility failed to offer and provide between-meal snacks to 4 of 4 residents (Residents' #5, #16, #20, and #25) reviewed for snacks and 3 additional residents (Residents' #29, #35, and #42) who participated in the Resident Council Interview. This failure had the potential to cause unmet nutritional needs for residents who resided in the facility. Findings include: The facility's policy titled, Food and Nutrition Services, revised 10/2017, documented nourishing snacks are available to the residents 24 hours a day and the resident may request snacks or snacks may be scheduled between meals to accommodate the resident's typical eating patterns. 1. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including diabetes and chronic obstructive pulmonary disease (COPD). On 9/17/24 Resident #5 was assessed to be cognitively intact. On 10/8/24 at 4:35 PM, Resident #5 stated she was diabetic and staff did not offer her between-meal snacks, and snacks were not always available when she requested them. Resident #5 stated she kept snacks she purchased in her room and felt it was not right for her to buy snacks when the facility should be providing them. 2. Resident #25 was admitted to the facility on [DATE] with multiple diagnoses including diabetes and chronic respiratory failure. On 8/20/24 was assessed to be cognitively intact. On 10/7/24 at 3:40 PM, Resident #25 stated the facility did not offer between-meal snacks and specified when he requested a snack, the staff would report there were no snacks available. 3. Resident #16 was admitted to the facility on [DATE] with multiple diagnoses including COPD and chronic pain syndrome. On 9/5/24 Resident #16 was assessed to be moderately cognitively impaired. On 10/7/24 at 4:15 PM, Resident #16 stated the facility did not offer snacks between meals and specified when they asked for a snack the staff would state there were no snacks to provide. 4. Resident #20 was admitted to the facility on [DATE] with multiple diagnoses including COPD and chronic kidney disease. On 10/1/24 Resident #20 was assessed to be cognitively intact. On 10/7/24 at 4:04 PM, Resident #20 stated between-meal snacks were not offered by staff or provided when requested. Resident #20 stated when he asked for a snack, staff would tell him no snacks were available. 5. On 10/8/24 at 2:00 PM, during the Resident Council Interview, 5 of 11 residents (Residents #5, #20, #29, #35, #42) who expressed concerns that staff did not offer them between-meal snacks and did not always receive a snack when they requested one. The Resident Council Meeting Minutes, from 04/25/24 to 09/26/24 documented the following resident concerns regarding in between meal snacks: On 4/25/24, one resident stated, we never get snacks passed. On 6/26/24, five residents stated, We never get snacks anymore unless we ask and often [staff] never come back even when we do. Makes us feel like we are begging, and we should not have to do that at our age. On 7/25/24, five residents stated, We never get snacks, but we always see aides eating them. On 10/10/24 at 9:40 AM the resident refrigerator on the facility's Annex hallway was observed to have available snacks and included half sandwiches, puddings, and juices. On 10/10/24 at 11:10 AM the resident refrigerator on the facility's Main hallway was observed to have available snacks and included half sandwiches, puddings, and juices. On 10/10/24 at 10:00 AM, LPN #2 stated snacks were available during the day shift but not always available during the night shift. LPN #2 specified by 10:00 PM, all resident snacks were gone and because the kitchen was closed, there were not any snacks to give to the residents who ask for them. On 10/10/24 at 4:00 PM, the DM stated there should be a variety of snacks available to offer to residents between meals and the kitchen checks and replenishes the snacks multiple times during the day. The DM stated the kitchen staff restock snacks before the kitchen closes at 7:00 PM and does not know why the staff state there are no snacks available. On 10/11/24 at 10:00 AM, the Administrator stated he expected residents to be able to receive a snack when they requested a snack.

Based on record review, staff interview, and resident interview, it was determined the facility failed to ensure a therapeutic diet was served to 1 of 3 residents (Resident #29) who were prescribed renal diets. This failure placed Resident #29 at risk for complications related to her kidney disease. Findings include: The facility's undated policy titled Therapeutic Diets documented the Dietary Manager will establish and use a tray identification system to ensure each resident receives their diet as ordered. Resident #29 was admitted to the facility on [DATE] with multiple diagnoses including diabetes, and end stage renal disease dependent on renal hemodialysis (a treatment using a machine to replicate kidney function, removing waste from the bloodstream). Resident #29's record documented a physician order, written on 6/12/24, for her to receive a CCHO/Renal (consistent carbohydrate/kidney healthy) diet. Resident #29's dietary meal slip directed the kitchen staff to serve her a Renal/CCHO diet and specified the foods she dislikes. The meal slip included documentation she disliked bananas and oranges. On 10/8/24 at 3:30 PM, Resident #29 stated she is often served bananas and oranges. Resident #29 added she liked oranges very much but because they were not recommended for someone prescribed a renal diet, she had a difficult time resisting temptation and wished the kitchen would follow her meal slip and not send food she should not eat. On 10/9/24 at 8:30 AM, the Dietary Manager stated the prescribed therapeutic diets are noted on the meal slips on each residents' tray and the kitchen staff use menu therapeutic extensions to determine appropriate substitutions. He stated Resident #29 should not have been served oranges if she had them listed as something she disliked, and because they were not recommended for people prescribed a renal diet. The DM stated he did not know why Resident #29 was served oranges when her meal slip directed not to serve oranges.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents were protected from significant medication errors. This was true for 1 of 1 resident (Resident #42) reviewed for medication errors. This deficient practice created the potential for harm when the facility failed to administer Resident #42's blood pressure medication for four consecutive days Findings include: The facility's Medication Errors policy and procedure, release date January 2023, documented a medication error as any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the health care professional, resident, or consumer. Resident #42 was admitted to the facility on [DATE], with multiple diagnoses including diabetes, high blood pressure, and schizophrenia. A nurse progress note, dated 5/18/24, documented Resident #42 continued to have elevated blood pressures and his physician prescribed Losartan 50 mg (a medication used to lower high blood pressure) to begin 5/19/24. An Incident Report, initated 5/28/24, documented RN #1 did not administer Resident #42's Losartan, as ordered, for four consecutive days (5/20/24-5/23/24). The incident report documented the error was discovered by RN #2 on 5/24/24. RN #2 informed the RCM it appeared Resident #42's Losartan doses had not been removed from the blister pack since 5/19/24. During the facility's investigation RN #1 was interviewed and stated she administered every dose of Resident #42's Losartan as ordered. When RN#1 was asked why 4 doses remained in the blister pack for the dates she worked she stated, there must have been a second blister pack of this medication delivered by pharmacy. On 5/30/24 the DON spoke with a pharmacy representative who stated only 1 card of 30 Losartan tablets was delivered to the facility for Resident #42 on 5/19/24. The facility's investigation concluded RN #1 documented she had administered Resident #42's Losartan on those 4 days but the medication had not been administered. On 10/11/24 at 10:00 AM, the DON confirmed RN #1 did not administer Resident #42's Losartan as ordered on May 20, 21, 22, and 23. Following the identification of the medication error, the facility completed the following corrective actions to prevent medication errors: -immediate physical assessment was preformed for Resident #42 and continued to have elevated blood pressures, but did not require emergent treatment. -Resident #42's physician was notified, and orders were received to increase his blood pressure medications -RN #1 was placed on administrative leave on 5/30/24. -provided medication error education to all licensed nurses on 6/6/24. -An audit of the Cubex medication storage was completed, and there were no concerns identified. -RN #1 was terminated from employment on 6/7/24. These findings represent past-noncompliance with this regulatory requirement, there was sufficient evidence the facility had corrected the noncompliance as of 6/7/24, and there were no other occurrences of significant medication errors. At the time of the survey, the facility was in substantial compliance for this regulatory requirement and, therefore, does not require a plan of correction.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to honor known food preferences for 2 of 2 residents (Resident's #10 and #25) reviewed for food choices. This failure created the potential to cause nutritional needs to go unmet for residents who consumed food prepared from the facility's kitchen. Findings include: The facility's policy titled, Food and Nutrition Services, revised 10/2017, documented each resident is provided with a nourishing, palatable, well-balanced diet to meet their daily nutritional and special dietary needs, taking into consideration the preferences of each resident and reasonable efforts will be made to accommodate resident choices and preferences. 1. On 8/20/24 Resident #25 was assessed to be cognitively intact. On 10/7/24 at 3:40 PM, Resident #25 stated his food preferences were noted on his meal tray slip but the kitchen staff did not follow the slip when preparing his meals, so his preferences were not honored. On 10/9/24 at 8:20 AM, Resident #25 was observed in the main dining room waiting to be served his breakfast. Resident #25 stated pancakes were being served, and his meal tray slip noted his preference to be served peanut butter with his pancakes. Resident #25 stated the kitchen staff frequently forget to serve peanut butter with his pancakes. On 10/9/24 at 8:23 AM, Resident #25 was observed being served his breakfast. His meal tray slip documented, Please send peanut butter w/[with] waffles, french toast, and pancakes. Resident #25's meal tray was observed to have pancakes as planned, there was no peanut butter observed on his tray. Resident #25 stated, see, they forgot to put peanut butter on my tray again. On 10/9/24 at 8:40 AM, the Administrator confirmed Resident #25 did not have peanut butter served on his breakfast tray as his meal tray slip directs. On 10/9/24 at 8:50 AM, the DM stated Resident #25's meal tray slip was not followed and he should have been served peanut butter with his pancakes. 2. On 7/7/24, Resident #10 was assessed to be cognitively intact. On 10/9/24 at 8:21 AM, Resident #10 was observed in the main dining room with his breakfast meal tray placed on the table in front of him. Resident #10's plate was observed to have 2 hard fried eggs on it. Resident #10's meal tray slip documented his preferences and included the statement, no eggs at breakfast. Resident #10 stated he informed the staff he did not want to be served eggs. On 10/9/24 at 8:50 AM, the DM stated Resident #10's preferences documented on his meal slip were not followed and he should not have been served eggs.

Based on policy review, I&A review, record review, and review of the facility's investigation report, it was determined the facility failed to ensure adequate supervision for residents to prevent falls. This was true for 1 of 1 resident (Resident #60) whose record was reviewed for falls. This resulted in harm to Resident #60 when the proper supervision was not provided. Findings include: Resident #60 was admitted to the facility on [DATE], with multiple diagnoses including osteoporosis (bone disease that develops when bone mineral density and bone mass decreases, which can lead to a decrease in bone strength and increase risk of fractures), and dementia. A smoking safety evaluation, dated 4/17/23, documented Resident #60 required supervision to ensure all smoking materials were returned to a locked box. The smoking evaluation did not document Resident #60 required assistance with mobility while in the smoking area. The care plan, dated 4/17/23, documented Resident #60 was a smoker and the charge nurse was to be notified immediately if Resident #60 was suspected of violating the facility smoking policy. The care plan documented Resident #60 was a 1-person extensive assist with ambulation until evaluated and cleared by physical therapy. The care plan did not include documentation Resident #60 required supervision while smoking. An I&A report, dated 4/18/23, documented Resident #60 had a fall with injury on 4/18/23 at 6:30 PM, while outside unsupervised in the smoking area. An X-ray report dated 4/19/23 at 1:58 PM, documented Resident #60 had a right femoral neck fracture (hip fracture). Resident #60 was transferred to the emergency room for further evaluation. The final I&A report, dated 4/26/23, documented an RN escorted Resident #60 to the smoking area and left her unsupervised. During that time Resident #60 attempted to stand up but her wheelchair brakes were not on, and she fell . The report documented the RN stated she escorted Resident #60 out to the smoking area and left her without supervision. She also stated she was unaware Resident #60 required assistance with ambulation and transfers and supervision while smoking. The facility's investigation, dated 4/26/23, concluded the fall was an avoidable fall with injury. The facility took the following corrective actions in response to the investigation: - Resident #60 was transported to the hospital. The care plan and Kardex (informational filing system that is used as a quick reference for health care providers that gives a brief overview of each patient and is updated every shift) were updated to include fall interventions/smoking supervision upon admission. - Review of residents in the facility to identify those at highest risk of falls with supervision requirements was conducted by the DON. Identified residents were placed on a visual identifier system, to alert staff to supervision requirements. - Review of residents who smoke was conducted to validate supervision requirements were in place on the care plan/Kardex and supervision was provided as needed. - Center staff were educated on provision of supervision for ADLs and smoking per the care plan and Kardex. - Protocol developed for visual identifier program and review for any needed modifications by the Quality Assurance and Program Improvement (QAPI) committee. - Newly admitted residents had the baseline care plan/Kardex posted at each nurses station for new and part time staff to review as part of the shift to shift report process. - DON conducted audits of care plans/Kardex to validate that supervision requirements were in place for smoking and ADLs as indicated. - DON conducted interviews with staff members regarding the process for reviewing the care plans and Kardex for residents at shift to shift report and the visual identification system to validate staff knowledge of processes and process changes. - Audits were conducted weekly for 4 weeks and then monthly for 3 months until substantial compliance was achieved. The facility provided documents of their plan of correction and their date of completion of all action items were complete by 9/7/23. I&A reports and facility grievances were reviewed from April through October 20,2023. There were no reports discovered of avoidable falls with injuries. Based on the corrective action taken by the facility and provision of documentation of those actions; and no other incidences of avoidable falls with injury after the 4/18/23 date of Resident #60's fall, the facility was cited for past non-compliance as of 9/7/23.

Based on facility document review and staff interview, it was determined the facility failed to meet regulation requirements for the participation of Quality Assessment and Assurance (QAA) committee members in the Quality Assurance and Performance Improvement (QAPI) meetings. This failure had the potential to negatively affect all residents in the facility if quality deficiencies throughout the facility were not identified and responded to timely and appropriately. Findings include: On 10/19/23 at 5:39 PM, the Administrator stated the QAA team was comprised of the Medical Director, Pharmacy Consultant, the Interdisciplinary Team, and department managers. He added meetings were mandatory and to be held at least quarterly, and the facility chose to hold the meetings monthly. The Monthly QAPI Participation sign-in sheets from February 2023 to September 2023, did not include documentation the Medical Director and Pharmacy Consultant participated in the QAPI meeting in February, March, April, May, and June. The Administrator stated he was not able to provide documentation these professionals had participated in a QAPI meeting in those quarters.

Based on policy review, review of grievance logs, and staff interview, it was determined the facility failed to ensure resident grievances were promptly addressed and the responses to the grievances documented. These deficient practices placed residents at risk of ongoing frustration and decreased sense of self-worth, as well as unmet care needs when their concerns were not promptly addressed by the facility. Findings include: The facility's Grievance policy and procedure, revised 3/2019, documented it was the facility's policy to support each resident's right to voice concerns/grievances. The facility should actively seek resolution to concerns and attempt to keep the individual who filed grievance updated on progress toward resolution. This policy further documented the Social Services Director should log all concerns/grievances received onto the facility grievance log, ensure completed with appropriate actions and follow-up, keep a running log of concerns voiced and their resolutions as well as a copy of the completed grievance forms. This policy was not followed. Facility grievance logs included the following findings: -8/2/23 through 8/31/23, 6 of 21 entries logged had no grievance form present -9/7/23 through 9/27/23, 1 of 5 entries logged had no grievance form present -10/3/23 through 10/16/23, 3 of 6 entries logged had no grievance form present On 10/18/23 at 9:57 AM, the Activities Director stated the Resident Council meeting minutes were reviewed after each meeting and formal grievances were written for any concerns noted on the minutes and then given to the Social Services Director. The Activities Director stated if the Resident Council could not meet because of precautions, such as COVID, she would offer each resident a 1 on 1 chance to voice concerns and write any concerns on a grievance form. On 10/18/23, at 11:00 AM, the Social Services Director stated the grievances were received by the Activities Director and then she logged the grievances and distributed them to the appropriate departments to address concerns. She stated when the concerns were addressed, the grievances were returned to her and a resolution date and outcome were written on the log. The Social Services Director reviewed the logs and stated she did not know where the missing or incomplete grievances were. She stated she did not have a system in place to ensure grievances were returned or completed.

Based on observation, record review, policy review, resident interview, and staff interview, it was determined the facility failed to ensure pre and post dialysis assessments were completed and accurate, an emergency kit was available at the bedside, and orders were followed for 3 of 6 residents (#25, #29, and #31) who received hemodialysis. This created the potential for adverse outcomes such as acute blood loss from the access site, infection of the access site, electrolyte imbalance, low blood pressure, and anemia. Findings include: 1. Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including hemodialysis (purifying the blood of a person whose kidneys are not working normally) for end stage kidney disease and Type 2 Diabetes. Resident #31 had an AV fistula to her left upper arm for dialysis. An AV fistula is a surgical connection between an artery and a vein for individuals who require permanent access to receive long-term hemodialysis. Resident #31's record included a care plan related to dialysis. The care plan documented Resident #31 had an arteriovenous (AV) fistula to her left arm for dialysis and she attended dialysis each Monday, Wednesday, and Friday. The care plan included interventions to assess for a thrill and bruit of the fistula every shift while awake (to ensure the fistula is working). A thrill is a vibration caused by blood flowing through the fistula and can be felt by placing your fingers on the fistula. A bruit is a whooshing sound heard through a stethoscope placed on the site. The care plan also documented not to draw blood or take a blood pressure using the left arm and to keep an emergency clamp in her room in case there was bleeding from the fistula. Resident #31's record included physician orders for hemodialysis three times a week on Monday, Wednesday, and Friday. The orders documented Resident #31's blood glucose was to be checked prior to dialysis on her scheduled days, an emergency dialysis kit at the head of the bed, and to assess once a day for signs and symptoms of infection to the fistula. Physician orders also included to remove her pressure dressing from the fistula 4-6 hours after completion of dialysis. Resident #31's care plan and physician orders were not followed. a. Resident #31's pre and post dialysis evaluations were inaccurate and did not include appropriate assessments. Examples include: i. Resident #31 had an AV fistula for hemodialysis located on her left upper arm. The pre and post dialysis evaluations, dated 9/1/23 to 10/16/23, did not include the accurate type and location of her access site and did not include complete assessments of her AV fistula to ensure there were no complications and that it was working. - A post dialysis evaluation, dated 9/1/23 at 6:50 PM, documented Resident #31's AV fistula was in her left forearm, not her left upper arm. The thrill from the fistula was not assessed. - Post dialysis evaluations dated 9/4/23, 9/6/23, 9/11/23, 9/13/23, 9/18/23, 9/20/23, documented Resident #31 had a central venous catheter, she had an AV fistula. The evaluations included assessments of a central venous catheter site. They did not include documentation Resident #31's fistula was assessed for signs and symptoms of complications and infection. - Post dialysis evaluations, dated 9/8/23, 9/29/23, 10/4/23, 10/6/23, 10/9/23, 10/11/23, and 10/13/23, did not include documentation Resident #31's AV fistula was assessed for a thrill. - A post dialysis evaluation, dated 9/15/23, documented Resident #31 had both a central venous catheter and AV fistula. The evaluation documented assessment of both access sites. Resident #31 did not have a central venous catheter. - A post dialysis evaluation, dated 9/26/23, documented Resident #31 had an AV fistula. There was no documentation where it was located and it was not assessed for a bruit or thrill, signs or symptoms of infection, edema, or pain, and whether the dressing was in place with no bleeding. ii. On 10/16/23 at 4:06 PM, Resident #31 was in her room after returning from the dialysis facility. She stated on dialysis days she left around 10:40 AM because it was scheduled to start at 11:00 AM and returned around 4 PM to 4:40 PM. Resident #31's pre and post dialysis evaluations, dated 9/1/23 to 9/30/23, were not completed prior to dialysis and upon return from dialysis to assess and monitor her condition for any changes and potential complications, as follows: - A pre dialysis evaluation was completed on 9/1/23 at 6:49 PM, almost 8 hours after her scheduled dialysis start time. - A pre dialysis evaluation was completed on 9/4/23 at 2:17 PM, almost 4 hours after her scheduled dialysis start time. - A pre dialysis evaluation was completed on 9/6/23 at 4:10 PM, 5 hours after her dialysis start time. - A post dialysis evaluation was completed on 9/6/23 at 11:01 PM, more than 6 hours after her scheduled return time from dialysis. - A pre dialysis evaluation was completed on 9/8/23 at 6:33 PM, more than 7 hours after her scheduled dialysis start time. - A pre dialysis evaluation was completed on 9/11/23 at 1:41 PM, almost 3 hours after her scheduled dialysis start time. - A pre dialysis evaluation was completed on 9/13/23 at 2:32 PM, almost 4 hours after her scheduled dialysis start time. - A post dialysis evaluation was completed on 9/13/23 at 9:59 PM, almost 6 hours after her scheduled return from dialysis. - A pre dialysis evaluation was completed on 9/15/23 at 5:41 PM, almost 7 hours after scheduled dialysis start time. - A pre dialysis evaluation was completed on 9/18/23 at 1:40 PM, almost 3 hours after her scheduled dialysis start time. - A pre dialysis evaluation was completed on 9/20/23 at 12:57 PM, almost 2 hours after her scheduled dialysis time. - A pre dialysis evaluation was completed on 9/22/23 at 9:10 PM, almost 10 hours after her scheduled dialysis start time. There was no post dialysis evaluation completed on 9/22/23. - A pre dialysis evaluation was completed on 9/25/23 at 1:54 PM, almost 4 hours after her scheduled dialysis start time. There was no post dialysis evaluation completed on 9/25/23. - A pre dialysis evaluation was completed on 9/29/23 at 5:59 PM, almost 7 hours after her scheduled dialysis start time. The post dialysis evaluation was documented as completed at the same time as the pre dialysis evaluation. iii. Resident #31's blood glucose was not measured prior to her dialysis per her physician order on the following days: - A pre dialysis evaluation, dated 8/23/23, documented Resident #31's most recent blood glucose was 170 mg/dL on 8/21/23 at 11:52 AM, 2 days prior. - A pre dialysis evaluation, dated 8/25/23, documented Resident #31's most recent blood glucose was 168 mg/dL on 8/23/23 at 9:35 AM, 2 days prior. - A pre dialysis evaluation, dated 8/28/23, documented Resident #31's most recent blood glucose was 139 mg/dL on 8/30/23 at 10:47 AM, 2 days after the date of the evaluation. The same blood glucose measurement was documented on the 8/30/23 pre dialysis evaluation. - A pre dialysis evaluation, dated 9/1/23, documented Resident #31's most recent blood glucose was 139 mg/dL on 8/30/23, 2 days prior. - A pre dialysis evaluation, dated 9/8/23, documented Resident #31's most recent blood glucose was 148 mg/dL on 9/6/23, 2 days prior. - A pre dialysis evaluation, dated 9/15/23, documented Resident #31's most recent blood glucose was 104 mg/dL on 9/13/23, 2 days prior. - A pre dialysis evaluation, dated 9/22/23, documented Resident #31's most recent blood glucose was 10 mg/dL on 9/20/23, 2 days prior. - A pre dialysis evaluation, dated 9/29/23, documented Resident #31's most recent blood glucose was 150 mg/dL on 9/27/23, 2 days prior. - A pre dialysis evaluation, dated 10/6/23, documented Resident #31's most recent blood glucose was 135 mg/dL on 10/4/23, 2 days prior. - A pre dialysis evaluation, dated 10/13/23, documented Resident #31's most recent blood glucose was 161 mg/dL on 10/11/23, 2 days prior. iv. Resident #31's pre dialysis evaluations, dated 9/1/23 to 10/16/23, did not include a complete set of current vital signs prior to her leaving for dialysis. - The pre dialysis evaluations dated 9/1/23, 9/4/23, 9/6/23, 9/8/23, 9/11/23, 9/13/23, 9/15/23, 9/18/23, 9/20/23, and 9/22/23, documented Resident #31's respiratory rate and temperature were last measured on 8/24/23. There was no documentation in the evaluations her respiratory rate and temperature were retaken or remeasured to assess for changes in status, for 28 days. - The pre dialysis evaluations dated 9/25/23, 9/29/23, 10/2/23, 10/4/23, 10/6/23, 10/9/23, 10/11/23, 10/13/23, and 10/16/23, documented Resident #31's respiratory rate was 18 per minute and were last measured on 9/24/23. There was no documentation in the evaluations her respiratory rate was remeasured for 21 days. b. Resident #31's record included an order to remove the pressure dressing from her AV fistula 4 to 6 hours after dialysis. There was no documentation in her record this was completed from 9/1/23 to 10/16/23. c. Resident #31's record included a laboratory and nutrition communication note from the dialysis facility dated 9/15/23. The note included a recommendation for Resident #31 to receive Renvela (a phosphorous binding agent) 800 mg 1 tablet with dinner. The note also documented phosphorous binders were to be given with meals and/or snacks and not during medication pass. Phosphorous binders work by attaching to some of the phosphate in food to help reduce the amount of phosphate being absorbed by the body. High phosphorous levels reduce calcium levels which may cause symptoms such as confusion, memory loss, delirium, depression, and hallucinations. Resident #31's MAR for September 2023 did not include an order or administration of Renvela 800 mg 1 tab with dinner. The MAR for October 2023 documented an order for Renvela 800 mg 1 tab at bedtime, which started on 10/5/23. The first dose was documented as given on 10/5/23, 19 days after it was recommended by the dialysis facility. It was also documented to be given at bedtime not dinner as recommended and per manufacturer instructions (Renvela.com, accessed on 10/26/23). d. The facility's policy Hemodialysis Care, last revised 7/2023, stated with an AV shunt (fistula) the resident's record included orders of emergency care and when to notify the physician. The policy stated emergency supplies may include a pressure dressing and emergency supplies are kept at the bedside. Resident #31 did not have the appropriate emergency supplies in her room. During an observation on 10/19/23 at 5:51 PM, there was a plastic bag hanging on a bulletin board behind the head of her bed with a [NAME] clamp inside (a device used to clamp blood vessels and hold heavy tissues in place, usually during surgery). There was no pressure dressing or other supplies for emergency use. On 10/18/23 beginning at 4:27 PM, Resident #31 was observed sitting on the side of her bed. She had her left upper arm covered with white gauze and a clear dressing over the gauze. Resident #31 stated she had just returned from dialysis. She stated the dressing was covering her fistula and she usually removed it herself around noon the following day. Resident #31 stated the nurses do not look at her arm after dialysis. During an interview, on 10/19/23 at 11:20 AM, the DON and Regional Support Nurse reviewed Resident #31's record. The DON stated the order for Renvela did not match the recommendation from the dialysis facility and she was not sure why it was scheduled for nighttime rather than with meals. She was unable to locate the orders for Renvela prior to 10/5/23. The DON and Regional Support Nurse verified the pre and post dialysis evaluations inaccurately documented Resident #31 had a central venous catheter and there was no assessment of her fistula documented. They also verified the timing of the evaluations did not demonstrate they were completed prior to dialysis and/or upon return. The DON verified the order for Resident #31's pressure dressing to be removed 4-6 hours after dialysis. She stated it was not documented because the order was put into the EMR on an as needed basis, rather than on Mondays, Wednesdays, and Fridays. On 10/19/23 at 5:52 PM, the DON was asked to view Resident #31's room at the emergency kit by her bedside. The DON was asked if this was an appropriate tool to stop bleeding from the dialysis fistula if it occurred and she stated no. 48402 2. Resident #25 was readmitted to the facility on [DATE], with multiple diagnoses including kidney failure and hemodialysis. The care plan, revised 10/16/23, documented Resident #25 required dialysis due to kidney failure. The care plan did not specify Resident #25's location or type of dialysis port (access to the body to administer dialysis). A physician order, dated 10/20/23, documented Resident #25 was to receive hemodialysis three times a week on Monday, Wednesday, and Friday. The orders did not include monitoring of Resident #25's dialysis site. Resident #25's pre dialysis evaluations, dated 10/6/23, 10/9/23, 10/11/23, and 10/13/23, documented Resident #25's respiratory rate and temperature were last assessed on 10/5/23. There was no documentation in the evaluation his respiratory rate and temperature were retaken or remeasured to assess for change in status for 8 days. Resident #25's pre and post dialysis evaluations dated, 10/6/23 to 10/18/23, were not completed prior to dialysis and upon return from dialysis to assess and monitor his condition for any change and potential complications, as follows: - A pre dialysis evaluation was completed on 9/22/23 at 5:34 PM, a post dialysis evaluation was completed on 9/22/23 at 5:34 PM, at the same time. - A pre dialysis evaluation was completed on 10/6/23 at 6:09 PM, a post dialysis evaluation was completed on 10/6/23 at 6:10 PM. The pre and post dialysis evaluations were documented 1 minute apart. - A pre dialysis evaluation was completed on 10/9/23 at 9:04 AM, a post dialysis evaluation was completed on 10/9/23 at 9:08 AM. The pre and post dialysis evaluations were documented 4 minutes apart. - A pre dialysis evaluation was completed on 10/13/23 at 5:45 PM, a post dialysis evaluation was completed on 10/13/23 at 5:47 PM. The pre and post dialysis evaluations were documented 2 minutes apart. - A pre dialysis evaluation was completed on 10/16/23 at 12:43 PM, a post dialysis evaluation was completed on 10/16/23 at 12:45 PM. The pre and post dialysis evaluations were documented 2 minutes apart. On 10/18/23 at 4:26 PM, the DON and Resource Nurse were interviewed together. The DON stated she could not provide an answer if the licensed nurses were assessing Resident #25 accurately. The Resource Nurse stated evaluations were not being done accurately. 48172 3. Resident #29 was admitted to the facility on [DATE], with multiple diagnoses including chronic respiratory failure and chronic kidney disease. Resident #29's pre dialysis evaluations, dated 10/9/23 and 10/11/23, documented vital signs were taken on dates other than the date of the evaluation as follows: - A pre dialysis evaluation, dated 10/9/23, documented a blood pressure and pulse on 10/12/23, 3 days after her dialysis. Resident #29's respirations and temperature were documented on 9/26/23, 14 days prior to her dialysis. Resident #29's blood glucose was documented on 10/13/23, 4 days after her dialysis. - A pre dialysis evaluation, dated 10/11/23, documented her blood pressure and pulse on 10/12/23, 1 day after her dialysis. Resident #29's respirations and temperature were documented on 9/26/23, 15 days prior to her dialysis. Resident #29's blood glucose was documented on 10/13/23, 2 days after her dialysis. On 10/19/23, at 4:06 PM, Resident #29 stated the nurses never took her vital signs before she went to dialysis. She stated the dialysis center took her vital signs at the center. On 10/19/23 at 10:00 AM, the DON reviewed Resident #29's pre dialysis evaluations dated 10/9/23 and 10/11/23 for vital signs. She stated she would have to ask the nurse about vital signs being completed before dialysis. The DON stated vital signs were to be taken before a resident leaves for dialysis.

Based on record review, policy review, and staff interviews, it was determined the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing or worsening. This was true for 2 of 6 residents (Resident #9 and Resident #10) whose records were reviewed for wounds. This resulted in harm to Resident #9 and Resident #10 when they had worsening and/or new wounds. The National Pressure Injury Advisory Panel website, accessed on 8/16/22, defined pressure ulcer staging as follows: Stage 1- Intact skin with a localized area of non-blanchable (skin that does not turn white when pressed with a finger) [CONDITION(S)] (red discoloration of the skin resulting from injury), which may appear differently in darkly pigmented skin. The presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate a deep tissue pressure injury. Stage 2 - Partial-thickness skin loss with exposed dermis (thick layer of living tissue below the epidermis which forms the true skin, containing blood capillaries, nerve endings, sweat glands, hair follicles, and other structures). The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible, and deeper tissues are not visible. Granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process), slough (non-viable yellow, tan, gray, green, or brown tissue), and eschar (dead or weakened tissue that is hard or soft in texture - usually black, brown, or tan in color) are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Stage 3 - Full-thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and epibole are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining (when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge) and tunneling (channels that extend from a wound into and through the tissue or muscle below) may occur. Fascia (thin casing of connective tissue that surrounds and holds every organ, blood vessel, bone, nerve fiber, and muscle in place), muscle, tendon, ligament, cartilage, or bone is not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Stage 4 - Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Unstageable - Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (dry, adherent, intact without [CONDITION(S)] or fluctuance) on an ischemic limb or the heel(s) should not be softened or removed. Deep tissue injury - Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). The facility's policy Skin at Risk/Skin, dated 9/2020, stated a resident who enters the facility without a pressure ulcer/injury will not develop a pressure ulcer/injury and a resident having pressure ulcer/injury receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. The policy also stated the facility will notify the physician and obtain a treatment order if needed, document on the treatment record after implemented and notify the resident's representative of skin condition and the treatment plan. The policy stated wounds that require less than daily dressing changes or treatment are checked for dressing placement at least daily. This policy was not followed. 1. Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] and 7/21/22, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS assessment, dated 6/1/22, documented Resident #10 was not at risk for pressure ulcers. The assessment documented, he had open [CONDITION(S)] on the foot which were not pressure ulcers, rashes, or cuts. The assessment also documented Resident #10 had moisture associated skin damage. The MDS assessment included treatments for the feet which were related to nutrition, hydration, and wound dressings. The assessment documented Resident #10 was always continent of bowel and bladder. Resident #10 developed wounds to his right lower extremity, left lower extremity, and coccyx, as follows: a. A history and physical, dated 5/25/22 and signed by the Medical Director, documented Resident #10 had a large blister to the top of his left foot and a small blister to the top of the fifth toe on his right foot. The Medical Director documented a blister was drained and the fluid was sent for culture. The history and physical did not document which blister was drained. The Medical Director documented the plan was to apply [MEDICATION(S)] (a gel to help heal wounds) to the wound and cover with cotton wrap twice a day. A skin evaluation assessment documented, beginning on 5/25/22, Resident #10 had a wound to the right outer ankle which measured 2 cm x 2 cm x 1 cm. An NP progress note, dated 5/31/22, documented a blister was drained on 5/26/22 and the fluid was sent for a culture. The note did not specify which blister was drained. The NP progress note documented Resident #10 had scattered blisters to both lower extremities. The progress note did not include measurements of Resident #10's blisters. An NP progress note, dated 6/1/22, documented Resident #10 had blistering and weeping to both lower extremities which was worsening. The note documented nursing staff were changing the wound dressings 6-7 times a day. The NP documented she consulted with the wound care clinic and Resident #10 had an appointment for 6/8/22 at 9:00 AM. The NP documented the wound care clinic also had Resident #10 on the cancellation list to try and get him in earlier. A skin evaluation assessment, dated 6/2/22, documented the wound to Resident #10's right outer ankle measured 2 cm x 2 cm x 1.5 cm. An NP progress note, dated 6/3/22, documented Resident #10 was transferred to the hospital for evaluation of his cardiac status. Resident #10 was admitted to the hospital. A hospital progress note, dated 6/3/22, documented Resident #10 had extensive areas of redness and swelling to both lower extremities. The note documented Resident #10 had large blisters on the top of his feet which were ruptured and had 2 smaller blisters on the right outside heel. There were no wound measurements documented in the hospital progress note. A hospital progress note, dated 6/5/22, documented Resident #10 had extensive areas of redness and swelling to both lower extremities. The note documented Resident #10 had large blisters on the top of his feet which were ruptured and had 2 smaller blisters on the right outside heel. The progress note documented they were improving. There were no wound measurements documented in the hospital progress note. An NP progress note, dated 6/8/22, documented Resident #10 was readmitted from the hospital where he was admitted for [CONDITION(S)] (a life-threatening infection) related to [CONDITION(S)] of both lower extremities. The note documented Resident #10 received antibiotics for the infection and had wound debridement (a procedure to remove dead tissue from a wound) at the hospital on 6/7/22. The NP documented Resident #10's wounds had improved significantly with the antibiotics. A skin evaluation assessment, dated 6/9/22, documented the wound to Resident #10's right outer ankle measured 2 cm x 2 cm x 0.1 cm. An NP progress note, dated 6/10/22, documented Resident #10 had dressings covering both lower extremities and the blisters on the top of both feet had drained. An NP progress note, dated 6/13/22, documented nursing staff reported Resident #10's wounds to his feet were improving and looking much better. An NP progress note, dated 6/21/22, documented Resident #10 had dressings covering both lower extremities and the blisters on the top of both feet had drained. An NP progress note, dated 6/22/22, documented Resident #10 had dressings covering both lower extremities and the blisters on the top of both feet had drained. An NP progress note, dated 6/23/22, documented Resident #10 had dressings covering both lower extremities and the blisters on the top of both feet had drained. A skin evaluation assessment, dated 6/23/22, documented the wound to Resident #10's right outer ankle measured 4 cm x 6 cm x 0.1 cm. The wound had increased in size 2 cm x 4 cm in 14 days. A wound clinic note, dated 6/29/22, documented Resident #10 had 4 wounds to his right lower extremity and were measured on 6/20/22. The location and measurements were documented, as follows: - Right outer foot, 3 cm x 4 cm x 0.05 cm - Right outer ankle, 2 cm x 3.2 cm x 0.05 cm - Right top of foot, 4.7 cm x 6.8 cm x 0.05 cm - Right top of ankle, 0.5 cm x 0.5 cm x 0.05 cm The same wound clinic note documented the location and measurements of the wound to Resident #10's right lower extremity for 6/28/22, as follows: - Right outer foot, 3.2 cm x 3 cm x 0.05 cm - Right outer ankle, 2.5 cm x 4 cm x 0.05 cm - Right top of foot, 4.8 cm x 6 cm x 0.1 cm - Right top of ankle, 0.5 cm x 0.5 cm and covered with eschar Resident #10's record did not include documentation of the wounds to his right outer foot and top of right foot. There was no documentation in Resident #10's record of a second wound to his right ankle. A skin evaluation assessment, dated 6/30/22, documented the wound to Resident #10's right outer ankle measured 3.8 cm x 5.8 cm x 0.1 cm. There was no documentation of the 3 other wounds identified by the wound clinic to Resident #10's right lower extremity. A wound clinic note, dated 7/6/22, documented Resident #10 had 6 wounds to his right lower extremity, 2 more than his previous visit 7 days ago. The location and measurements were documented, as follows: - Right outer foot, 2.9 cm x 5 cm x 0.1 cm - Right outer heel, 2 cm x 2.7 cm x 0.1 cm - Right top of foot, 4 cm x 6 cm x 0.2 cm - Right top of ankle, 0.3 cm x 0.5 cm x 0.05 cm - Right fifth toe, 1 cm x 0.8 cm x 0.05 cm - Right back heel, 0.7 cm x 0.9 cm x 0.1 cm The wound clinic note also documented the bottom of Resident #10's right foot was white, weeping, and saturated with moisture. An NP progress note, dated 7/5/22, documented Resident #10 had dressings covering both lower extremities and the blisters on the top of both feet had drained. An NP progress note, dated 7/11/22, documented Resident #10 had dressings covering both lower extremities and the blisters on the top of both feet had drained. A skin evaluation assessment, dated 7/7/22, documented the wound to Resident #10's right outer ankle measured 3.5 cm x 5.5 cm x 0.1 cm. There was no documentation in Resident #10's record of the wounds to his right outer foot, right outer heel, right top of foot, right fifth toe, and right back heel. The facility skin assessment was inconsistent with the wound clinic assessment dated [DATE], 1 day prior. A wound clinic note, dated 7/13/22, documented Resident #10 had 6 wounds to his right lower extremity, 2 more than his previous visit 7 days ago. The location and measurements were documented, as follows: - Right outer foot, 3 cm x 3 cm x 0.05 cm - Right outer heel, 2 cm x 3 cm x 0.05 cm - Right top of foot, 4.6 cm x 6 cm x 0.1 cm - Right top of ankle, 0.5 cm x 0.7 cm x 0.05 cm - Right fifth toe, 1 cm x 1 cm x 0.05 cm - Right back heel, 0.7 cm x 0.7 cm x 0.05 cm The note also documented the dressings on Resident #10's lower extremities were excessively moist and both feet were saturated with moisture and peeling. A skin evaluation assessment, dated 7/14/22, documented the wound to Resident #10's right outer ankle measured 3.5 cm x 5.5 cm x 0.1 cm. There was no documentation in Resident #10's record of the wounds to his right outer foot, right outer heel, right top of foot, right fifth toe, and right back heel. The facility skin assessment was inconsistent with the wound clinic assessment dated [DATE], 1 day prior. Resident #10 was admitted to the hospital on 7/15/22. A wound visit was completed by the wound clinic provider while he was in the hospital, on 7/18/22. The wound clinic progress note, from the hospital, documented Resident #10 had ulcerations to the right outer foot, right outer heel, top of the right foot, right top of ankle, right fifth toe, and right back heel. There were no measurements included in the progress note of the wounds. The note also documented both of Resident #10's feet were saturated with moisture and peeling. An NP progress note, dated 7/21/22, documented Resident #10 was readmitted to the facility that day. The note documented Resident #10 had [CONDITION(S)] to both lower extremities and they had wound dressings which were warm and dry. Skin evaluation assessments, dated 7/21/22, documented Resident #10 had multiple wounds to his right lower extremity, as follows: - Top of the right foot, 6 cm x 6.5 cm - Right big toe, 1 cm x 1.4 cm x 0.05 cm - Right fourth toe, 0.5 cm x 0.5 cm - Right fifth toe, 1.3 cm x 1 cm - Right outer mid foot, 0.5 cm x 0.5 cm - Right outer ankle, 4 cm x 5 cm x 0.05 cm - Right outer back ankle, 3 cm x 3 cm x 0.05 cm - Right back ankle, deep tissue injury 1.7 cm x 1.4 cm - Right back of calf, 5 cm x 2 cm x 0.5 cm - Right inner calf, 1.5 cm x 1 cm x 0.05 cm - Right outer calf, 0.4 cm x 0.3 cm x 0.1 cm - Right outer calf, 1.6 cm x 1.2 cm x 0.05 cm - Right lower calf, 1 cm x 1.6 cm x 0.05 cm There were two skin evaluation assessments for Resident #10 on 7/21/22. One skin evaluation assessment documented 5 wounds to his right foot. The wound to the top of Resident #10's right foot stated there was eschar/slough, the other 4 wounds to his right foot did not have further description. The second evaluation documented a description of Resident #10's right back calf and stated the wound bed was pink and yellow, the other 7 wounds to his right calf did not have further description. Resident #10 had a total of 13 wounds to his right lower extremity with a description for 2 of the 13 wounds. An NP progress note, dated 7/25/22, documented Resident #10 had wound dressings to both lower extremities which were warm and dry. An NP progress note, dated 7/27/22, documented Resident #10 had wound dressings to both lower extremities which were warm and dry. The note documented Resident #10 had significant wounds to both bilateral extremities which were followed by the wound care clinic. An NP progress note, dated 7/28/22, documented Resident #10 had wound dressings to both lower extremities which were warm and dry. The note documented Resident #10 had significant wounds to both bilateral extremities which were followed by the wound care clinic. The NP documented in the progress note at 12:59 PM, there were no maggots in the wounds at the time of her assessment. Nursing progress notes, dated 7/28/22 from 12:26 PM and 12:27 PM, documented Resident #10's wound dressings were changed, and the wounds had deteriorated. The skin evaluation assessments for Resident #10, dated 7/28/22, did not document changes to his 13 wounds. Nursing progress notes, dated 7/28/22 from 12:26 PM and 12:27 PM, documented Resident #10's wound dressings were changed and the wounds had deteriorated. A nursing note, dated 7/29/22 at 1:04 AM, documented at 10:15 PM on 7/28/22 Resident #10 had a decreased level of consciousness and had a strong odor from the left foot. The note documented the dressing was removed and there were maggots in between the first four toes and to the top of the foot. The nursing note documented a verbal order was received to cleanse the wound and send Resident #10 to the ER. A nursing note, dated 7/29/22 at 5:45 AM, documented at 3:00 AM on 7/29/22 Resident #10 returned from the ER by ambulance. The note documented orders were received to continue frequent dressing changes to bilateral feet and lower legs. The nursing note documented the NP would be in to evaluate that day. A nursing note, dated 7/29/22 at 5:48 AM, documented at 6:00 PM on 7/28/22 Resident #10 had a foul odor coming from the left foot. The note documented there were maggots between the left first four toes and to the top of the left foot. The nursing note documented the maggots measured approximately 2 mm. The nursing notes dated 7/29/22 at 5:45 AM and 5:48 AM, conflicted with the time of the discovery of the odor to Resident #10's left foot and the presence of maggots. The first note documented this was discovered at 10:15 PM the second note documented this was discovered at 6:00 PM, a difference of 4 hours and 15 minutes. A nursing note, dated 7/29/22 at 7:13 PM, documented a late entry for 7/28/22 which stated Report on friday [sic] 7/26/22 morning that resident had been sent to ER [sic] for maggots in wound during the night, upon receiving report in am resident appear [sic] up in hallway self propelling. RCN [sic] in to do wound care and measurements note to looked [sic] great and cleaned out at that point per rcm [sic] team. The date of 7/26/22 was a Tuesday not a Friday. There was no further documentation regarding the current status of Resident #10's wounds. An ER note, dated 7/28/22, documented Resident #10 presented to the ER at 11:37 PM on 7/28/22. The ER physician documented Resident #10 had a 10 cm wound to the top of his right foot, without odor, and was infested with maggots. Resident #10 was discharged back to the facility at 3:12 AM on 7/29/22. The ER physician documented to continue the wound care per facility orders and to keep the wound covered with frequent dressing changes. An NP progress note, dated 7/29/22, documented Resident #10 had a maggot infestation during the night. The note documented the wound clinic NP was consulted and Resident #10 was sent to the ER for evaluation and cleansing of his wounds. The note documented Resident #10 returned from the ER the same night and his wounds were assessed that morning and were free of maggots and there were no signs of infection. The nursing note, dated 7/30/22 at 3:24 AM, documented the dressings to Resident #10's wounds were intact and had no drainage. There were no previous nursing notes about Resident #10's wounds after his return from the ER. This was 24 hours after his return from the ER, where his wounds were evaluated for maggots. A nursing note, dated 7/31/22 at 5:44 AM, documented the dressings to Resident #10's lower legs were intact without drainage. A nursing note, dated 7/31/22 at 7:00 PM, documented Resident #10 was slow to respond in the morning and appeared confused. The note documented Resident #10 stated he had difficulty swallowing and coughing when he took his morning medications and the pain in his lower legs was extremely uncomfortable. The nursing note documented Resident #10's facial color went from pale with pink cheeks to pale, dusky gray and the NP was notified regarding his increased pain, confusion, decreased responsiveness, and cold, blue tinged hands. The note documented Resident #10 was currently in the ER. The note did not include documentation of what time the NP was notified of Resident #10's change in condition and when he was sent to the ER. A nursing note, dated 7/31/22 at 7:25 PM, documented it was a late entry without the date or time. The note documented wound care was performed due to Resident #10's dressing being saturated. Maggots were noted to wound bed and between toes, wounds were cleansed per provider order and Resident #10 was sent to the ER. An EMS note, dated 7/31/22, documented Resident #10 presented to the ER at 3:29 PM via ambulance. An ER note, dated 7/31/22, documented Resident #10 was seen 2 days ago in the ER for concerns about maggots in his foot wound and increased weakness. The ER physician documented Resident #10 was discharged back to the facility and has returned with maggots in his foot wounds. The ER physician documented Resident #10 had very deep wounds to his right foot with tendons exposed. The note also documented the dressing was removed and there were maggots on the dressing. The ER physician documented Resident #10 had .similar but smaller and more superficial wounds to his left foot, it did not state there were maggots. b. A history and physical, dated 5/25/22 and signed by the Medical Director, documented Resident #10 had a large blister to the top of his left foot and a small blister to the top of the fifth toe on his right foot. The Medical Director documented a blister was drained and the fluid was sent for culture. The history and physical did not document which blister was drained. The Medical Director documented the plan was to apply [MEDICATION(S)] to the wound and cover with cotton wrap twice a day. Skin evaluation assessments documented, beginning on 5/25/22, Resident #10 had a wound to the top of the left foot which measured 6 cm x 9 cm x 2.5 cm. An NP progress note, dated 5/31/22, documented a blister was drained on 5/26/22 and the fluid was sent for a culture. The note did not specify which blister was drained. The NP progress note documented Resident #10 had scattered blisters to both lower extremities. The progress note did not include measurements of Resident #10's blisters. An NP progress note, dated 6/1/22, documented Resident #10 had blistering and weeping to both lower extremities which was worsening. The note documented nursing staff were changing the wound dressings 6-7 times a day. The NP documented she consulted with the wound care clinic and Resident #10 had an appointment for 6/8/22 at 9:00 AM. The NP documented the wound care clinic also had Resident #10 on the cancellation list to try and get him in earlier. A skin evaluation assessment, dated 6/2/22, documented Resident #10's wound to the top of the left foot was 6 cm x 9 cm x 2.5 cm and was a fluid filled blister. A skin evaluation assessment, dated 6/2/22, documented Resident #10 had a new wound to the left big toe which measured 2 cm x 2 cm x 1.5 cm and was a fluid filled blister. An NP progress note, dated 6/3/22, documented Resident #10 was transferred to the hospital for evaluation of his cardiac status. Resident #10 was admitted to the hospital. A hospital progress note, dated 6/3/22, documented Resident #10 had extensive areas of redness and swelling to both lower extremities. The note documented Resident #10 had large blisters on the top of his feet which were ruptured and had 2 smaller blisters on the right outside heel. There were no wound measurements documented in the hospital progress note. A hospital progress note, dated 6/5/22, documented Resident #10 had extensive areas of redness and swelling to both lower extremities. The note documented Resident #10 had large blisters on the top of his feet which were ruptured and had 2 smaller blisters on the right outside heel. The progress note documented they were improving. There were no wound measurements documented in the hospital progress note. An NP progress note, dated 6/8/22, documented Resident #8 was readmitted from the hospital where he was admitted for [CONDITION(S)] (a life-threatening infection) related to [CONDITION(S)] of both lower extremities. The note documented Resident #10 received antibiotics for the infection and had wound debridement (a procedure to remove dead tissue from a wound) at the hospital on 6/7/22. The NP documented Resident #10's wounds had improved significantly with the antibiotics. A skin evaluation assessment, dated 6/9/22, documented Resident #10's wound to the top of the left foot was 6 cm x 9 cm x 2.5 cm and was a fluid filled blister. It was unclear if Resident #10 had developed a new blister to the top of his left foot. A skin evaluation assessment, dated 6/9/22, documented Resident #10's wound to the top of the left big toe was 2 cm x 2 cm x 1.5 cm and was a fluid filled blister. It was unclear if Resident #10 had developed a new blister to the top of his left toe. The skin evaluation assessments for Resident #10's wounds dated 6/2/22 and 6/9/22, to the top of his left foot and the left big toe, documented no change in measurement or description for both wounds. An NP progress note, dated 6/10/22, documented Resident #10 had dressings covering both lower extremities and the blisters on the top of both feet had drained. An NP progress note, dated 6/13/22, documented nursing staff reported Resident #10's wounds to his feet were improving and looking much better. The skin evaluation assessment, dated 6/16/22, documented Resident #10's wound to the top of the left foot was 6 cm x 9 cm x 0.1 cm and had minimal drainage of clear fluid and the blister had ruptured. A second skin evaluation assessment, dated the same day, documented Resident #10's wound to his left big toe measured 2 cm x 2 cm x 0.1 cm and minimal drainage of clear fluid and the blister had ruptured. The skin evaluation assessments, dated 6/16/22, documented a slight change in the depth measurement of the left big toe but no change in the measurements of the top of Resident #10's left foot. A wound clinic note, dated 6/20/22, documented Resident #10 had 2 wounds to the left foot, the top of the foot and the outer ankle. The wound to the top of the left foot measured 4 cm x 8.8 cm x 0.05 cm. The wound to the left outer ankle measured 3.2 cm x 4 cm x 0.05 cm. An NP progress note, dated 6/21/22, documented Resident #10 had dressings covering both lower extremities and the blisters on the top of both feet had drained. An NP progress note, dated 6/22/22, documented Resident #10 had dressings covering both lower extremities and the blisters on the top of both feet had drained. An NP progress note, dated 6/23/22, documented Resident #10 had dressings covering both lower extremities and the blisters on the top of both feet had drained. The skin evaluation assessment, dated 6/23/22, documented Resident #10's wound to the top of his left foot was 5.85 cm x 8.85 cm x 0.1 cm, a decrease of 0.15 cm x 0.15 cm, and continued to have minimal drainage of clear fluid. The skin evaluation assessment of Resident #10's left big toe, dated the same day, documented it measured 0.5 cm x 0.5 cm x 0.05 cm and had minimal drainage of clear fluid. There was no documentation of a wound to the left outer ankle in Resident #10's record. There was no documentation in the wound clinic note of the wound to Resident #10's left big toe. The wounds identified by the facility and the wound clinic were not consistent in location and measurements. An NP progress note, dated 6/27/22, documented Resident #10 had dressings covering both lower extremities and the blisters on the top of both feet had drained. A wound clinic note, dated 6/29/22, documented Resident #10 had 3 wounds to the left lower extremity. There was documentation of wounds to the top of the left foot which measured 3.3 cm x 7.5 cm x 0.05 cm, the left outer heel which measured 3 cm x 4 cm x 0.05 cm, and to the left outer ankle which measured 0.3 cm x 0.6 cm x 0.1 cm. The clinic note documented Resident #10's [CONDITION(S)] was resolved and the remaining wounds were full-thickness on both lower extremities. The skin evaluation assessments, dated 6/30/22, documented Resident #10's wound to his top left foot was unchanged in size and had a moderate amount of drainage of clear fluid. The skin evaluation assessment of Resident #10's left big toe, dated the same day, documented it measured 0.45 cm x 0.45 cm x 0.05 cm. Resident #10's record did not include documentation of wounds to his left outer heel and left outer ankle. The wound to the top of Resident #10's left foot was larger than the measurement documented by the wound clinic on 6/29/22, 1 day prior, a difference of 2.35 cm x 1.35 cm x 0.05 cm. The wound clinic's note from 6/29/22 also did not include documentation of a wound to Resident #10's left big toe. An NP progress note, dated 7/5/22, documented Resident #10 had dressings covering both lower extremities and the blisters on the top of both feet had drained. An NP progress note, dated 7/11/22, documented Resident #10 had dressings covering both lower extremities and the blisters on the top of both feet had drained. A wound clinic note, dated 7/13/22, documented Resident #10 had 3 wounds to the left lower extremity. The wounds to the top of the left foot measured 3 cm x 8 cm x 0.05 cm, the left outer heel was 2.7 cm x 3.2 cm x 0.05 cm, and the left outer ankle measured 0.2 cm x 0.4 cm x 0.1 cm. The note also documented the wound dressings were excessively moist and the bottoms of Resident #10's feet had softened due to prolonged exposure to liquid and were peeling. An NP progress note, dated 7/13/22, documented Resident #10 had dressings covering both lower extremities and the blisters on the top of both feet had drained. A skin evaluation assessment, dated 7/7/22, documented the wound to the top of Resident #10's left foot measured 5.5 cm x 8.5 cm x 0.1 cm and had a moderate amount of clear drainage and the wound was improving. A second skin evaluation assessment, dated the same day, documented the wound to Resident #10's left big toe measured 0.4 cm x 0.4 cm x 0.05 cm and had a minimal amount of clear drainage and there was no change. There was no documentation of the wound to Resident #10's left outer heel. A skin evaluation assessment, dated 7/14/22, documented the wound to the top of Resident #10's left foot measured 5.5 cm x 8 cm x 0.1 cm and was draining a heavy amount of clear fluid. The evaluation documented Resident #10's wound had improved. A skin evaluation assessment, dated 7/14/22, documented the wound to Resident #10's left big toe measured 0.4 cm x 0.4 cm x 0.05 cm and was draining a small amount of clear fluid and there was no change. An NP progress note, dated 7/15/22, documented Resident #10 was weak, sleepy, and had swelling up to his face and was sent to the hospital for worsening symptoms of heart failure. Resident #10 was admitted to the hospital on 7/15/22. A wound visit was completed by the wound clinic provider while he was in the hospital, on 7/18/22. The wound clinic progress note from the hospital doc

Based on policy review, record review, review of the State Survey Agency's Long- Term Care Reporting Portal, and resident and staff interview, it was determined the facility failed to ensure residents were free from sexual abuse. This was true for 4 of 6 residents (#2, #3, #6, and #7) reviewed for abuse. Further, 8 additional instances of abuse to unnamed female residents were referenced in Resident #1's record (the perpetrator). This deficient practice placed the health and safety of Resident #2, #3, #6, and #7 and the other 28 female residents residing in the facility, in immediate jeopardy of serious harm, impairment, or death. Findings include: Resident #1 was admitted to facility on 5/20/21 with multiple diagnoses, including adjustment disorder with depressive mood (experiencing more stress than would normally be expected in response to a stressful life event), and suicidal ideation. Resident #1's record included a physician note, dated 6/24/21, which documented Resident #1 was alert and oriented to person, place, time, and situation with some impairment in his insight. The facility's abuse policy, dated 2/2019, stated sexual abuse included sexual harassment and sexual assault. Sexual harassment included inappropriate comments or actions. Sexual assault was defined as unwanted sexual contact which included kissing and fondling. The policy further stated, It is the policy of this center to .Protect our residents from abuse. The policy was not followed. 1. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses, including Alzheimer's Disease and dementia. A quarterly MDS assessment, dated 5/17/22, documented Resident #2 was cognitively intact. a. A reportable incident report, dated 5/15/22, documented Resident #2 was speaking to Resident #1 in the hallway when he proceeded to rub her arm and moved his hand up to her breast repeatedly. Resident #2 stated Resident #1 started touching my arm and telling me how much he loves me and things he was going to [sic] with me. Resident #2 stated she had her arms crossed because she was not wearing a bra. The report documented Resident #2 said Resident #1 kept touching me, then he moved his hand up to my breast. He kept rubbing his hand back and [forth] to my arm and breast and he told me he loves to watch me and my roommate when we are in our room through the window. b. A progress note, dated 5/15/22 at 8:00 PM, documented LN #1 went to Resident #2's room to administer her night medications. The note documented Resident #2 took her medications and asked LN #1 to close her door and stated, I don't want [Resident #1] close to me. I am so afraid of him. The note further documented when LN #1 asked Resident #2 why she was afraid of Resident #1, she stated, after playing bingo yesterday she went to her room, the door was closed, and staff were helping her roommate. She stated she waited outside the room and Resident #1 followed and came close to her. Resident #2 stated Resident #1 started touching her arm and telling her how much he loved her and things he was going to do with her. The note documented Resident #2 stated she had her arms crossed because she was not wearing a bra and Resident #1 kept touching her and moved his hand up to her breast. She stated she was so embarrassed and told Resident #1 she only wanted a friendship. Resident #2 stated Resident #1 told her he loved to watch her and her roommate when they were in their room through her window. The note documented Resident #2 stated, I do not want this man close to me and I was so embarrassed and afraid and don't want nothing happen [sic] to him. The note documented emotional support was provided to Resident #2 and she was reassured she was safe in the facility and a safety plan was put in place. The safety plan included a Behavior Monitoring Log. Resident #1's Behavior Monitoring Log, undated, stated staff were to monitor Resident #1 and document when he was observed wandering into female resident rooms, touching residents without permission, and using sexual/vulgar language towards other residents. The log stated if Resident #1's behaviors were observed, staff were to talk with [Resident #1] about behaviors, redirect behaviors, [and] minimize risk. Resident #1's Behavior Monitoring Log did not include documentation how often staff were to monitor Resident #1 or how staff were to redirect behaviors and minimize risk. A progress note, dated 5/15/22 at 11:45 PM, documented Resident #2 told LN #2 she was feeling uncomfortable and told LN #2 Resident #1 touched her breast without her permission. It was unclear how the facility would specifically keep Resident #2 safe from Resident #1. c. Resident #1's current care plan did not include interventions to address wandering into female resident rooms, touching residents without permission, and using sexual and/or vulgar language towards other residents. Resident #1's care plan did not include how the facility would protect Resident #2 and other residents from Resident #1's sexual behavior. d. A room change notification form, dated 5/16/22, documented Resident #1's room change was for the safety of other residents due to Resident #1's inappropriate sexual behavior. A progress note, dated 5/16/22 at 12:32 PM, documented Resident #2 was very vocal about her distress over her encounter with Resident #1. She asked that her door be kept closed and she did not wish to see Resident #1. The note documented Resident #2 came to an activity to get a donut but asked to be taken back to her room when she saw Resident #1 in the common area. The note further documented donuts were brought to Resident #2's room and she was cheerful but facial expression quickly change [sic] to concern and fear if subject brought up. It was unclear how the facility would specifically keep Resident #2 safe from Resident #1. e. A Sexual Behavior Adjunct Evaluation, dated 5/16/22, documented Resident #1's behavior was described as inappropriate sexual language, touching, and sitting outside residents' rooms watching them. The evaluation documented, Behaviors are directed towards other residents, and over the weekend he groped another resident [sic] chest. Made comments that he watches [Resident #2] through the window. That he is in love with her. The evaluation documented [Resident #1's] son, who was his POA was called. The evaluation did not document what time and who called Resident #1's son. The evaluation documented Resident #1's son was aware of his father's behaviors and he had the behaviors for the past few years. The evaluation documented [Resident #1] stated that he didn't do anything. The evaluation further documented Requesting for a Psychological assessment and evaluation to be done with a request for medication or treatment plan. Looking for a more long-term plan for an all-male facility to meet his needs. [Resident #1] refuses to have any type of psychosocial assessment and he has never had any sexual inappropriate behaviors. It was unclear how the facility would specifically keep Resident #2 safe from Resident #1. f. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #1] continues to have sexual deviant behavior, inappropriately touching other residents in the facility . [Resident #1] does have significant paraphilia (a condition characterized by abnormal sexual desires, typically involving extreme or dangerous activities), has been on medication for quite some time and increased with success, however this time patient is actually touching private parts of resident [sic] .Law enforcement stated they would follow-up however they failed to do so. [Resident #1] been [sic] removed from that part of facility placed [sic] on the other side away from [Resident #2] and under strict [sic] from nursing due to inappropriate behaviors. Did increase [Resident #1's] medication, [MEDICATION(S)], to try and decrease patient [sic]. However, patient is continuing to exhibit inappropriate behaviors. [Resident #1] referred to all male facility referral [sic] as soon as possible due to continued paraphilia. g. A progress note, dated 5/17/22, documented Resident #2 would receive counseling and an order from the physician was processed. The note documented Resident #2 went to an evening activity but stated if Resident #1 attended the activity she wanted to return to her room. h. A progress note, dated 5/19/22 at 1:58 PM, documented Resident #2 was upset and a little teary in the morning. The note documented Resident #2 stated she might need her daughter to look for another place for her. Resident #2 stated she did not want to run into Resident #1. i. A progress note, dated 6/9/22, documented Resident #2 reported she was not going to afternoon activities because she was upset after attending bingo in the morning and Resident #1 was there. Resident #2 stated I felt like I was going to get sick. It upset me so that he [Resident #1] was there the whole time. It was unclear how the facility would specifically keep Resident #2 safe from Resident #1. j. A social services progress note, dated 6/13/22 at 1:53 PM, documented nursing reported Resident #2 was anxious and visibly upset and Resident #2 felt vulnerable when she was left alone in the dining room. The note documented the SSD met with Resident #1 during the past several weeks and Resident #2 continued to be very anxious and upset by being violated by another resident [Resident #1] who touched her arm and breast. The note further documented the issue was addressed and a safety protocol was established. The note documented Resident #2 was having a hard time sleeping and constantly worried. The SSD spoke with the NP and asked for Resident #2 to be started on medication for anxiety. The note documented Resident #2 would be set up for more counseling, and social services would meet with Resident #2 once a week if needed and check on her more often. A progress note, dated 6/13/22 at 2:03 PM, documented Resident #2 appeared agitated and she was in fear of another resident in the facility. The note documented Resident #2 stated she was the last person in activities in the morning and she felt Resident #1 may be in the corner or somewhere near. Resident #2 also stated she had a panic attack and felt very vulnerable. The note further documented Resident #2 stated she did not sleep more than 20 minutes at a time and was aware of every noise. Resident #2 also stated, I have been groped and molested and if my family finds out they will come after him [Resident #1]. k. A Social Service Quarterly Review, dated 6/25/22, documented Resident #2 was stable and without issues until last month when she reported another resident [Resident #1] touched her without permission. The Social Service Quarterly Review further documented this event triggered per past trauma and caused her anxiety. The review did not explain Resident #2's past trauma. The review documented due to Resident #2's increased anxiety, her blood pressure was elevated, and Resident #2 was started on a new medication [for her anxiety]. The review further documented a referral was made for counseling for Resident #2, her care plan was updated, and behavior monitoring was implemented. The review documented since Resident #2's last assessment, new onset of symptoms included agitation, social isolation, fear, severe anxiety, mistrust, and loss of interest or pleasure in activities. Telehealth (medical appointment via telecommunication in lieu of an in-person office or bedside appointment) counseling was started, and social services met with Resident #2 on a weekly basis. On 7/7/22 at 3:30 PM, Resident #2 described the incident from 5/15/22. She stated when Resident #1 touched her breast and nipple she was very embarrassed and afraid. She said she would not attend activities in the facility if Resident #1 was present. She said if she went to an activity and Resident #1 was there, she left the activity. When asked if Resident #1 came to her room since the incident, Resident #2's voice became shaky, and her eyes moistened as she stated Resident #1 came to her room at least three times in the last 7 days. She stated he once came early in the morning about 6:10 AM and stood in the doorframe. Resident #2 stated this frightened and upset her. Resident #2 stated she just wanted him [Resident #1] gone [out of the facility]. On 7/7/22 at 4:30 PM, the SSD stated the safety plan for Resident #1 was implementation of behavior monitoring and he was checked on every 2 hours. Resident #1's record did not include documentation he was checked on every 2 hours. Resident #2 experienced psychosocial and physical harm when the facility failed to ensure she was free from abuse and continued contact from Resident #1. 2. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly MDS assessment, dated 9/17/21, documented Resident #3 was severely cognitively impaired. a. A reportable incident, dated 9/13/21, stated Resident #3 was wheeling herself in her wheelchair toward the end of a hall. The report documented Resident #1 asked Resident #3 to come into his room. Once Resident #3 was in Resident #1's room, he wheeled his wheelchair behind Resident #3 and put his arms around her and kissed her on the cheek. The report documented Resident #3 stated, Oh my, help. A staff member separated the 2 residents. Resident #1's care plan, revised 9/13/21, included 2 interventions related to sexual behavior. The interventions were: Should [Resident #1] act sexually inappropriate to any staff member or resident, please let him know that this behavior is not appropriate at this facility .Should [Resident #1] speak in a sexually inappropriate manner, please stop the behavior and remove from the area. The care plan did not include interventions to address how to prevent Resident #1 from inappropriate sexual behavior or how to protect other residents from his sexual behavior. b. A progress note, dated 9/19/21, documented Resident #1 was displaying sexually inappropriate behavior and will continue to monitor. The note documented the proper departments were notified of Resident #1's behavior. The note did not include which departments were notified. c. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 had inappropriate sexual contact with another resident in the facility who was unable to make appropriate decisions for herself. The note further documented Resident #1 was warned about his behavior and was currently cognitively able to make decisions and fully aware of his behavior. The note documented there was another incident today where Resident #1 lured another resident [Resident #3] to his room to make inappropriate contact. Resident #1 was started on [MEDICATION(S)] (antidepressant used to treat depression and anxiety) a few weeks prior and did not demonstrate behaviors previously. The note documented the [MEDICATION(S)] dose would be gradually reduced, and Resident #1 would be started on [MEDICATION(S)] (antidepressant used to treat depression, including major depressive disorder) as it, diminished libido. A progress note, dated 9/20/21, documented Resident #1 had a new physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to ensure Resident #3 was free from sexual abuse. 3. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A reportable incident, dated 5/16/22, included documented interviews with residents as part of the investigation by the facility. a. An interview with Resident #6 documented she stated, Resident #1 stops by our room and 'I catch him sitting watching me, he is a pervert.' The interview further documented, Resident #6 stated, When Resident #7 was sharing a room, he (Resident #1) would sit and watch her get undressed. I would yell at him to 'Go the hell away'. If he ever touches me or anyone, I will kill him. b. An interview with Resident #7 documented she stated, I don't like him (Resident #1); I am with someone and I don't want him around me. There was no documentation in Resident #6 or Resident #7's records the facility followed-up or investigated these statements. It was unclear how the facility would specifically keep Resident #6 and #7 safe from Resident #1. On 7/7/22 at 5:20 PM, the CRN stated she was aware of Resident #6's negative comment and should have initiated further follow-up and reporting to the state portal. The facility failed to keep Resident #6 and Resident #7 free from sexual abuse. 4. Resident #1's record documented additional incidents of sexual abuse with unidentified female residents, as follows: a. A progress note, dated 10/4/21, documented Facility request for reevaluation [Resident #1] related to sexual inappropriate behavior/paraphilia with cognitive declined resident [unnamed] in the facility. [Resident #1] is known to lure the cognitive impaired patient into his room. The other patient willingly follows [Resident #1] and even seeks out sneaking into the [Resident #1's] room. The note documented Resident #1 was touching and kissing the resident who was cognitively impaired. The note further documented, the physician discussed Resident #1's behaviors with him and he agreed with increasing his [MEDICATION(S)] dose. It was unclear how the facility would specifically keep the unnamed resident safe from Resident #1. b. A progress note, dated 10/12/21, documented a CNA reported Resident #1 was having more inappropriate situations with another female resident [unnamed] and asking for kisses. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The note documented staff reported Resident #1 had decreased behaviors. Resident #1 was still asking for kisses, but no longer touching other female residents or attempting to coerce them into his room. Resident #1's [MEDICATION(S)] was increased to 30 mg daily. It was unclear how the facility would specifically keep the unnamed residents safe from Resident #1. c. A progress note, dated 2/13/22, documented [Resident #1] entered a female [unidentified] occupied room while seated in his wheelchair and parked at the foot of the first female occupants' bed. The female roommates started yelling 'get out of here' and all the staff feeding other patients in the dining room and this RN witnessed it and overheard it occurred .This author entered the female occupied room and clearly stated to [Resident #1] 'exit the room you need to leave.' He stated, 'I am not going to leave.' I then proceeded to approach his wheelchair stating I was going to remove him from the room via his wheelchair and he immediately backed out of the room approximately 4 feet and parked outside the doorway. The females stated they did not want him occupying their doorway and were 'fearful of him and he takes down our stop sign banner and still will come in get him to leave us alone again.' [Resident #1] was re-directed from their doorway and he proceeded to the main hall dining area. It was unclear how the facility would specifically keep the unnamed residents safe from Resident #1. d. A progress note, dated 2/17/22, documented a CNA reported Resident #1 was peering into a female resident's room, the female resident [unnamed] asked for Resident #1 to be kept out of her doorway. e. A progress note, dated 5/16/22 at 5:38 PM, documented [Resident #1] was sitting outside of female residents' room [unnamed] .[Resident#1] has been discussed with not to sit outside of rooms and look in. Redirected [Resident #1] to main dining area and asked him to not be stopping and looking into other residents' rooms for privacy and respect. [Resident #1] was not sure what the issue was, he said he does not stop and look into people's rooms, or at least into rooms that people don't seem to mind. Behavior log is at the nurse's station to fill out along with educational information and company policy. It was unclear how the facility would specifically keep the unnamed resident safe from Resident #1). f. A social services progress note, dated 5/26/22 at 11:34 AM, documented This morning [Resident #1] was seen touching another resident [unnamed], running his hands up her arm. Staff gave [Resident #1] a reminder for safety of touching and appropriateness. [Female] sic Resident he was touching did not appear to be in distress or disturbed by the incident and when ask if everything was OK, she responded with everything is fine. It was unclear how the facility would specifically keep the unnamed resident safe from Resident #1. g. A progress note, dated 6/2/22, documented [Resident #1] stopped outside a room that he has expressly been asked not to interact with the female [unnamed] inside per her request. [Resident #1] was overheard telling female resident that he still loves her. [Resident #1] was asked to move away from door and door was shut to prevent further interactions. [Resident #1] shows no indication that he was distressed with being asked to move along. It was unclear how the facility would specifically keep the unnamed resident safe from Resident #1. Resident #1's record did not identify which female residents Resident #1 had sexual encounters with or provide adequate interventions to prevent him from continued sexual behaviors and contact with female residents. On 7/7/22 at 4:30 PM, when asked why the event on 2/13/22 was not reported or investigated, the SSD stated she and the Administrator were not employed with the facility at that time and were unable to speak as to why it was not reported. She agreed the incident should have been reported and an investigation completed. On 7/7/22 at 5:30 PM an interview was conducted with the Administrator, DON, and SSD. The DON stated nurses were responsible for behavior monitoring for residents. She stated CNAs also documented behaviors for residents. The DON stated progress notes were reviewed daily and if a pattern of increased behavior occurred, a recommendation was made for interventions. She stated the IDT evaluated increased behaviors to identify the root cause and identify a new intervention. When asked where updated interventions were documented, the DON stated they should be documented in the resident's progress notes and care plan. When asked why there was no documentation on Resident #1's care plan regarding immediate interventions made to keep resident's safe, The Administrator, DON, and SSD agreed immediate interventions should have been documented and implemented on Resident #1's care plan. The facility's failure to ensure residents were free from sexual abuse placed all female residents in immediate jeopardy of serious harm, impairment, or death. On 7/7/22 at 6:32 PM, the Administrator and DON were notified verbally and in writing of an Immediate Jeopardy (IJ) determination at F600 related to the facility's failure to ensure residents were free from abuse. This failure placed Resident #2 and Resident #3, at increased likelihood for serious harm, injury, or death, as well as the other 28 female residents residing in the facility. On 7/8/22 at 9:55 am, the facility provided a plan to remove the immediacy which was accepted. The facility's IJ removal plan included: Resident #2 was assessed by the SSD, Resident #2's care plan was updated for interventions related to psychosocial and mood status. Resident #1was assessed by SSD related to his current behaviors, psychosocial status, and the plan of care was updated. Resident #1 was placed on 1:1 supervision until an adequate safety plan approved by the State Department of Health and Welfare was developed/implemented. On 7/8/22 at 9:55 AM, the Administrator and DON were verbally notified the immediacy was removed based on onsite verification the IJ removal plan was implemented. Following the removal of the immediacy, noncompliance remained at actual harm which was widespread.

Based on record review, policy review, review of the State Survey Agency's Long-Term Care Reporting Portal, and staff interview, it was determined the facility failed to ensure allegations of sexual abuse were investigated for 4 of 6 residents (#2, #3, #6, and #7) who were reviewed for potential abuse. Further, this was true for 2 additional unnamed residents referenced in Resident #1's record (the perpetrator). This failure caused psychosocial and physical harm to a resident when she was sexually abused. This deficient practice also placed the health and safety of all 31 female residents residing in the facility at risk. Findings include: The facility's abuse policy, dated 2/2019, stated it was the facility's expectation to investigate allegations of abuse. This policy was not followed. Resident #1 was admitted to facility on 5/20/21 with multiple diagnoses, including adjustment disorder with depressive mood (experiencing more stress than would normally be expected in response to a stressful life event), and suicidal ideation. Resident #1's record included a physician note, dated 6/24/21, which documented Resident #1 was alert and oriented to person, place, time, and situation with some impairment in his insight. The facility did not conduct a thorough investigation of allegations of abuse which resulted in continued behaviors and caused harm residents as follows: 1. A progress note, dated 2/13/22, documented [Resident #1] entered a female [unidentified] occupied room while seated in his wheelchair and parked at the foot of the first female occupants' bed. The female roommates started yelling 'get out of here' and all the staff feeding other patients in the dining room and this RN witnessed it and overheard it occurred .This author entered the female occupied room and clearly stated to [Resident #1] 'exit the room you need to leave.' He stated, 'I am not going to leave.' I then proceeded to approach his wheelchair stating I was going to remove him from the room via his wheelchair and he immediately backed out of the room approximately 4 feet and parked outside the doorway. The females stated they did not want him occupying their doorway and were 'fearful of him and he takes down our stop sign banner and still will come in get him to leave us alone again.' [Resident #1] was re-directed from their doorway and he proceeded to the main hall dining area. There was no documentation the facility investigated this incident of potential abuse. Resident #1's current care plan did not include interventions to address wandering into female resident rooms, touching residents without permission, and using sexual and/or vulgar language towards other residents. On 7/7/22 at 4:30 PM, when asked why the event on 2/13/22 was not reported or investigated, the SSD stated she and the Administrator were not employed with the facility at that time and were unable to speak as to why it was not reported. She agreed the incident should have been reported and an investigation completed. The facility failed to investigate allegations of abuse to the State Survey Agency's Long-Term Care Reporting Portal. 2. Resident #2 was admitted to the facility on [DATE], with multiple diagnoses, including Alzheimer's Disease and dementia. A quarterly MDS assessment, dated 5/17/22, documented Resident #2 was cognitively intact. A reportable incident report, dated 5/15/22, documented Resident #2 was speaking to Resident #1 in the hallway when he proceeded to rub her arm and, moved his hand up to her breast repeatedly. Resident #2 stated Resident #1, started touching my arm and telling me how much he loves me and things he was going to [sic] with me. Resident #2 stated she had her arms crossed because she was not wearing a bra. The report documented Resident #2 stated Resident #1, kept touching me, then he moved his hand up to my breast. He kept rubbing his hand back and [forth] to my arm and breast and he told me he loves to watch me and my roommate when we are in our room through the window. A Social Service Quarterly Review, dated 6/25/22, documented Resident #2 was stable and without issues until last month [May 2022] when she reported a resident [Resident #1] touched her without her permission. The Social Service Quarterly Review further documented this event triggered Resident #2's past trauma and caused her anxiety. The review did not explain Resident #2's past trauma. The review documented due to Resident #2's increased anxiety, her blood pressure was elevated, and Resident #2 was started on a new medication [for her anxiety]. The review further documented a referral was made for counseling for Resident #2, her care plan was updated, and behavior monitoring was implemented. The review documented since Resident #2's last assessment, new onset of symptoms included agitation, social isolation, fear, severe anxiety, mistrust, and loss of interest or pleasure in activities. Telehealth (medical appointment via telecommunication in lieu of an in-person office or bedside appointment) counseling was started, and social services met with Resident #2 on a weekly basis. On 7/7/22 at 4:30 PM, when asked why the event on 2/13/22 was not reported or investigated, the SSD stated she and the Administrator were not employed with the facility at that time and were unable to speak as to why it was not reported. She agreed the incident should have been reported and an investigation completed. The facility did not conduct a thorough investigation of allegations of abuse which resulted in continued behaviors and caused psychosocial and physical harm to Resident #2. 3. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7 was admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A reportable incident, dated 5/16/22, included documented interviews with residents as part of the investigation by the facility. a. An interview with Resident #6 documented she stated, Resident #1 stops by our room and 'I catch him sitting watching me, he is a pervert.' The interview further documented, Resident #6 stated, When Resident #7 was sharing a room, he (Resident #1) would sit and watch her get undressed. I would yell at him to 'Go the hell away'. If he ever touches me or anyone, I will kill him. b. An interview with Resident #7 documented she stated, I don't like him (Resident #1); I am with someone and I don't want him around me. There was no documentation in Resident #6 or Resident #7's records the facility followed-up or investigated these statements. On 7/7/22 at 5:20 PM, the CRN stated she was aware of Resident #6's negative comment and should have initiated further follow-up and reporting to the state portal. The facility failed to conduct a thorough investigations of allegations of abuse for Resident #6 and Resident #7.

Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents were free from unnecessary drugs. This was true for 1 of 5 residents (Resident #51) reviewed for unnecessary medications. This failure resulted in harm to Resident #51 when she fell and sustained a fracture from oversedation. Findings include: The facility's policy for Medication Regimen Review, undated, documented the following: * The consultant pharmacist performed a comprehensive medication regimen review (MRR) at least monthly. * The MRR included the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. Medication irregularities included unnecessary drugs and pertinent recommendations were reported to the DON, attending physician, and medical director and/or administrator. * The consulting pharmacist incorporated federally mandated standards of care and other professional standards. * A written diagnosis, indication, or documented objective information supported each medication order. * Indication for use and therapeutic goals were consistent with current medical writings and clinical practice guidelines. * Duplicated medication orders included a written rationale and evidence of monitoring for efficacy and adverse medication effects. * The administration schedule was appropriate for the resident, keeping in mind side effects (such as sedation), compatibility with other medications, and manufacturer's recommendations. * The resident's medical condition and response to medication therapy were evaluated to ensure the appropriateness of the medication regimen. * Resident irregularities or clinically significant risks related to medications were documented in the resident's record and reported to the DON, attending physician, and medical director as appropriate. Resident #51 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #51's physician orders [REDACTED]. * [MEDICATION NAME] (muscle relaxer) 10 mg three times a day. * [MEDICATION NAME] (medication to relieve nerve pain) 900 mg four times a day. * [MEDICATION NAME] (narcotic pain medication) extended release 15 mg three times a day. * [MEDICATION NAME]-[MEDICATION NAME] (narcotic pain medication) 10-325 mg four times a day as needed. * [MEDICATION NAME] (anti-anxiety medication) 1 mg twice a day as needed. According to Drugs.com a nationally recognized reference for medications, website accessed on 6/7/19, listed the common side effects for Resident #51's medications as follows: - [MEDICATION NAME]: clumsiness or unsteadiness and lack or loss of strength - [MEDICATION NAME]: lack or loss of strength - Bupoprion: dizziness - [MEDICATION NAME]: loss of balance - [MEDICATION NAME]: dizziness, drowsiness, lightheadedness - [MEDICATION NAME] Extended Release: drowsiness, sleepiness - [MEDICATION NAME]: sedation, lethargy (a lack of energy and enthusiasm) - [MEDICATION NAME]: drowsiness, sleepiness An I&A report documented Resident #51 fell on [DATE] at 12:50 PM, when she slid from her chair to the floor. The report documented Resident #51 leaned to the right in her wheelchair, fell asleep, and fell out of her wheelchair. The I&A stated there were no injuries at that time. Resident #51 had a previous fracture to her left arm and sustained a [MEDICAL CONDITION] arm at the time of the report. The report documented the fall was related to positioning, and Resident #51 was confused and fatigued. It was believed she fell on to her buttocks, but an x-ray was obtained of her right arm due to bruising and the resident's complaints of pain two days after the fall. The x-ray showed a [MEDICAL CONDITION] humerus. Resident #51's Progress Notes documented the following: * On 5/1/19, the attending physician documented on an admission examination of Resident #51, she was on a very high dose of [MEDICATION NAME] (antipsychotic medication) but that would be left up to her primary care physician. The note did not address other concerns or issues regarding her medications. * On 5/1/19, an Infectious Disease physician documented Resident #56 reports she is just tired from all the stuff recently. Patient is very drowsy and falls to sleep quickly .Per (physician name), advised to go to ER for eval and possible (N)arcan, but patient refuses repeatedly and requests ride back to nursing home. Called nursing home to verify patient's meds (medications) and drowsiness. [MEDICATION NAME] is a medication to reverse effects of narcotic medications. * On 5/10/19 at 1:56 PM, an RN documented Resident #51 slid from her chair to the floor onto her bottom. * On 5/15/19 at 7:01 PM, an RN documented a [MEDICAL CONDITION] humerus was noted by the orthopedic physician, and he wanted to see her in one week. * On 5/16/19 at 2:05 AM, an LPN documented Resident #51 rated her pain as 6 out of 10, but she did not want to take a narcotic pain medication because it made her too out of it. * On 5/16/19 at 1:54 PM, an RN documented Resident #51 continued leaning forward and to the right in her chair. Her right arm was outside of the armrest, causing impaired circulation to her arm and twisting her shoulder at an odd angle. She appears to be ready to fall out of her chair and is reminded to sit back and sit up. * On 5/18/19 at 1:54 PM: An LPN documented Resident #51 was very drowsy and falling asleep in her chair. Resident #51 was educated several times about keeping her arm in the sling; she said it was annoying and hurts so removed it and threw it on the floor when she wanted to sleep. She seemed really down .having a hard time not being able to use her arms. Resident #51 was interviewed and observed as follows: * On 5/21/19 at 9:27 AM, Resident #51 was sitting in her wheelchair in her room. She was leaning forward and to the right and appeared drowsy. * On 5/21/19 at 12:53 PM, Resident #51 was observed leaning over to the right side in her wheelchair with her eyes closed and head down towards her chest. She said she did not want lunch, and she appeared drowsy. * On 5/21/19 at 2:55 PM, Resident #51 was in her wheelchair in her room, leaning forward and to the right. She was awake off and on, her right arm was out of the sling hanging over the side of the wheelchair, and there were red/purple bruises on the inside of her right arm. She said she felt tired and drugged out and was tired of sitting in the chair. * On 5/22/19 at 1:58 PM, Resident #51 said she took a lot of pain medicine and some of it made her sleepy. She said she felt like she got too much medicine. * On 5/23/19 at 8:48 AM, Resident #51 said she fell because the night before the facility gave her 600 mg of a medication, the name of which she could not recall, and she was previously taking 50 mg, and it made her so loopy. On 5/22/19 at 4:23 PM, the DON said on the day Resident #51 fell , she just finished lunch, the aide got her ready for therapy, and she was waiting for the therapist to come in. A nurse came by and saw Resident #51 sitting on her buttocks on the floor, and she said she must have fallen asleep. On 5/22/19 at 4:46 PM, the DON said Resident #51's medications could be making her a little sleepy, and it was going to be addressed in the next medication review meeting. The DON said the pharmacist usually reviewed residents' medications at their next visit to the facility, and the pharmacist was in the facility during the survey. The DON said residents' medications were also reviewed by the pharmacy, and they would let the facility know if there were any concerns. She said if the facility noticed anything concerning regarding residents' medications they could ask the pharmacy. On 5/23/19 at 3:01 PM, the pharmacist said he just reviewed Resident #51's medications the previous evening. The pharmacist said he made some recommendations pertaining to Resident #51's psychoactive medications but did not make recommendations regarding her other medications. The pharmacist said Resident #51 had a lot of pain medication ordered, but he did not recommend anything different. The pharmacist said the facility was going to have a psychoactive medication meeting during the week of survey and they planned to discuss Resident #51's medications, but the he could not be there. The pharmacist said Resident #51 was a complicated case because of her diabetic [MEDICAL CONDITION], pain, and psychiatric history. On 5/24/19 at 9:03 AM, the DON said the pharmacist addressed Resident #51's antidepressant medications, and it was planned to have a [MEDICAL CONDITION] drug meeting the day before and discuss her medications, but it did not happen because of everything going on. The DON said the pharmacist said something about Resident #51's [MEDICATION NAME] (medication for nerve pain) but she needed the medication. The DON said the initial pharmacist's review did not mention concerns about Resident #51's medications, and the physician saw her but did not mention anything about her medications.

Based on observation, policy review, record review, resident and staff interview, it was determined the facility failed to allow residents to make choices regarding their smoking schedule. This was true for 1 of 4 (#15) residents sampled for resident rights. This deficient practice created psychosocial harm for Resident #15 when she felt discriminated against for not being allowed to smoke with other residents and her choices were not honored. Findings include: The Smoking policy, revised (MONTH) (YEAR), documented all residents who wished to smoke would be assessed and evaluated for safety. The policy documented An established set of criteria will be used to evaluate safety risk. Residents who do not meet the established criteria to smoke independently will be provided assistance/supervision during all smoking activities. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 5/24/18, documented Resident #15 was cognitively intact. The MDS assessment documented Resident #15 was totally dependent or required extensive assistance of one to two staff members for all cares. The care plan area addressing Resident #15's smoking, initiated 7/16/18, documented her family members were the only authorized individuals to assist with smoking. Smoking Evaluations and Care Conferences notes documented the following: * 4/27/18 - Care Conference Note - Resident requested care conference to discuss smoking concerns. Resident voices concerns of wanting to smoke. Resident states that she feels she has been discriminated against D/T (due to) being unable to smoke. RNCM states that D/T the fact she is unable to hold her cigarette it is not safe for her to smoke . (RSN) stated that family ONLY can administer cigarettes after a smoking assessment has been done and care plan it. Facility cannot assist with smoking D/T her inability to hold a cigarette. * 4/27/18 and 6/11/18 - Smoking Evaluations - The evaluations documented Resident #15 was unable to light, hold, or extinguish her smoking material and she required supervision with smoking. The evaluations documented the following summary, (Resident #15) will be supervised smoker with family, staff are not to supervise her smoking. (Resident #15) and her family are aware of the risks of her smoking and they accept responsibility as IDT (Interdisciplinary Team) does not feel resident is safe to smoke with staff supervision. Resident is to wear a smoking apron . Resident #15's unsigned consent, current Smoking Policy, dated (MONTH) (YEAR), documented the Resident #15 was unable to sign the document and the LSW had signed the consent on 8/9/18. On 8/6/18 at 3:20 PM, a facility sign was on a wall next to the exit door by the smoking area. The sign documented smoking times were 7:00 AM, 9:30 AM, 11:00 AM, 1:00 PM, 4:00 PM, 7:00 PM, and 8:30 PM. On 8/6/18 at 4:14 PM, Resident #15 stated she was a smoker when she could and the facility stopped her from smoking. Resident #15 stated she felt discriminated against because of her condition of being a quadriplegic. Resident #15 stated smoking was one of the last joys in life where she enjoyed socialization with other people, and she felt she was missing this by being segregated in her room and in bed all day. Resident #15 stated the facility told her the staff would not assist her smoking because of insurance reasons which she did not understand. Resident #15 stated she could hold the cigarette in her mouth and she was willing to wear a smoking apron. Resident #15 stated her family was responsible for assisting her with smoking and they did not always visit daily. Resident #15 stated she wanted the option to smoke at minimum 1-2 times a day with other residents. Resident #15 stated the only way the facility would let her smoke was to agree with her family assisting her even if it did not make her happy. On 8/7/18 at 9:57 AM, Resident #15 was observed in the smoking area wearing a smoking apron and a family member accompanied her. The family member was sitting in a chair next to Resident #15 talking with her and another resident with his arm crossed in his lap. Resident #15 had a cigarette in her mouth and her right arm was positioned on top of the smoking apron. The ash cup was observed on the table next to Resident #15. On 8/9/18 at 10:30 AM, the Business Office Manager stated she went over the smoking policy with residents on admit and informed residents that they had to be assessed to as supervised or independent smokers. The Business Office Manager stated she had residents document that they understood the smoking policy. On 8/9/18 at 11:18 AM, RCM #2 stated Resident #15 was not able to smoke independently and she required 1:1 supervision. RCM #2 stated staff would be required to hold the ash cup under the cigarette for the duration of the cigarette. RCM #2 stated currently there was only one staff member assigned to monitor all residents during the smoke breaks and she would require 1:1. RCM #2 stated the family had wanted to take the responsibility for providing this 1:1 supervision. RCM #2 was unable to answer if the facility was understaffed and unable to provide the 1:1 supervision. RCM #2 stated Resident #15's family should be holding Resident#15's ash cup up for the duration of her cigarette and if it was not done, this was not adequate supervision. On 8/9/18 at 11:27 AM, the DNS stated Resident #15's family agreed during a care plan meeting to supervise her during smoking. The DNS stated Resident #15 should be allowed to smoke during the regular supervised times and the family times should be a extra time in addition to this. RCM #3 stated Resident #15 was allowed to smoke only when her family was present. The DNS stated a resident should not feel discriminated against. The DNS stated Resident #15 should be allowed to visit with other residents during the smoking breaks. The DNS stated the facility had staff to assist Resident #15 1:1 during smoke breaks in addition to the scheduled personnel assigned. The RSN stated the facility would complete a new smoking evaluation for Resident #15. The DNS stated they could provide assistance for her to smoke during the supervised smoke breaks. On 8/9/18 at 1:34 PM, when asked why it was determined facility staff could not safety assist Resident #15 to smoke, the DNS stated the staff was competent to monitor her safety while smoking. The DNS stated she was not sure of the reason Resident #15's smoking evaluation stated staff could not safely assist her. The DNS stated staff were still working on reassessing Resident #15.

Based on resident and staff interview, record review, and review of a skin assessment spreadsheet, it was determined the facility failed to prevent the worsening of identified pressure ulcers and the development of new pressure ulcers. This was true for 1 of 3 residents (#41) reviewed for pressure ulcers. This failure resulted in harm to Resident #41 when her pressure ulcers worsened and she developed new pressure ulcers. Findings include: Resident #41 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission MDS assessment, dated 7/13/18, documented Resident #41 had severe cognitive impairment. The MDS assessment documented she required extensive assistance from 1 to 2 staff members for all cares. The MDS assessment documented she had 3 unstageable pressure ulcers and 3 stage three pressure ulcers present upon admission. The MDS documented one of the pressure ulcers was 5.7 cm by 3.5 cm by 0.4 cm with eschar. The MDS documented she had pressure reducing devices to her chair and bed, increased nutritional needs, and required pressure ulcer care. Johns Hopkins Medicine, website accessed on 8/30/18, stated A pressure ulcer is the result of damage caused by pressure over time causing an ischemia of underlying structures. Bony prominences are the most common sites and causes. The website stated an assessment of the wound should be done weekly and used to drive treatment decisions. A Stage III pressure ulcer is described as full thickness skin loss which may include undermining/tunneling. An unstageable pressure ulcer is full thickness skin loss which is covered by slough (dead tissue usually cream or yellow in color) or eschar (dry, thick, leathery dead tissue tissue that is often tan, brown or black). A Care Conference Report, dated 7/13/18, documented Resident #41 refused to get out of bed and she was admitted with multiple pressure ulcers and poor skin integrity. The care plan area addressing Resident #41's pressure ulcers, initiated 7/18/18, documented Resident #41 had alterations in her skin integrity and she was admitted with a Stage III pressure ulcer to her right outer ankle and an arterial ulcer to her right outer shin. The care plan documented she had poor skin integrity related to poor circulation and diabetes. The care plan did not include the other 2 Stage III pressure ulcers or the 3 unstageable pressure ulcers documented in Resident #41's 7/13/18 admission MDS assessment for Resident #41. Resident #41's physician's orders [REDACTED].>* Bordered foam to right lower extremity as needed, ordered 7/20/18. * Bordered foam to right ankle once every three days, ordered 7/20/18. * Bordered foam to wound on right outer shin once every three days, ordered 7/20/18. * Bordered foam dressing to open areas on the upper and mid back as need, ordered 7/25/18. * Bordered foam dressing to open area on the upper and mid back once every three days, ordered 7/25/18. The Weekly Skin Alteration Reports documented the following: a. The Weekly Skin Alteration Report of Resident #41's outside right ankle documented Resident #41 had a stage three pressure ulcer, first observed upon admission. The report documented the measurements were: * On 7/6/18, 7/10/18, and 7/17/18 the wound was documented as 2 cm by 1 cm with clear drainage and 100% slough. * On 7/20/18 the wound was documented as 2 cm by 0.7 cm with serous drainage and slough. * On 7/27/18 and 8/3/18 the wound was documented as 2 cm by 2 cm with white and yellow drainage and slough. The wound worsened with increased size and slough covering the wound base remained. On 8/7/18 at 4:11 PM, LPN #2 stated the bandage on Resident #41's ankle was changed earlier in the day on 8/7/18. LPN #2 found the soiled bandage from her ankle dressing and the bandage appeared to have a 5 cm round shaped lime green and yellow discharge on the bandage. b. Resident #41 developed 2 new skin impairment areas on her back, as follows: The Weekly Skin Alteration Report of Resident #41's middle back documented Resident #41 had an excoriated area, first observed on 7/25/18. The report documented the measurements were: * On 7/25/18 and 7/27/18 the wound was documented as 2 cm by 1 cm. * On 8/3/18 the wound was documented as resolved. The Weekly Skin Alteration Report of Resident #41's upper back documented Resident #41 had an excoriated area, first observed on 7/25/18. The report documented the measurements were: * On 7/25/18 the wound was documented as 3 cm by 5 cm with 100% granulation. * On 7/27/18 the wound was documented as 2.5 cm by 5 cm with granulation. * On 8/3/18 the wound was documented as resolved. c. Resident #41 developed a new pressure ulcer area on her right second toe. On 8/6/18 at 5:47 PM, Resident #41's second toe was observed with a 1 cm eschar area on her right foot. On 8/7/18 from 9:47 AM through 4:11 PM, Resident #41's second toe was observed with a 1 cm eschar area on her right foot. On 8/7/18 at 4:11 PM, LPN #2 stated he had not noticed Resident #41's second toe before then. Resident #41's 7/9/18 through 8/8/18 MAR indicated [REDACTED]. Examples include: * Bordered foam dressing to the mid and upper back, right ankle, and right shin was not changed on 7/23/18, 7/28/18, 7/29/19, 8/1/18, 8/3/18, 8/4/18 and 8/6/18. Resident observation and interviews: On 8/6/18 at 5:47 PM, Resident #41 was observed laying in bed with a pillow under her back on her left-side. On 8/7/18 from 9:47 AM through 4:11 PM, Resident # 41 was observed on her back with a pillow under her right arm and her legs flush on the bed. Resident #41's right ankle and right calf were positioned flat against the mattress. On 8/7/18 at 10:42 AM, Resident #41's bilateral legs were observed with flaking skin and her toenails were observed yellow and thick. Resident #41's right leg was observed with a bandage on the outside of her right ankle and an ACE bandage on her right shin. On 8/7/18 at 12:11 PM, Resident #41 stated she was not always provided pain medications prior to dressing changes and when she was not provided the medications she would refuse related to pain. Resident #41 stated when she was provided pain medications the dressing changes could be managed. On 8/7/18 at 4:11 PM, LPN #2 stated Resident #41's feet should be floated on a pillow. On 8/8/18 from 8:37 AM to 5:56 PM, Resident #41's right ankle and her right calf were observed positioned flat against the mattress. On 8/8/18 at 1:12 PM, Resident #41 was observed during a dressing change to her right shin. Resident #41's leg was positioned back on the mattress after LPN #4 completed the dressing change. Resident #41 cried out during the dressing change saying, Ow. On 8/8/18 at 1:44 PM, LPN #2 stated he did not document the injury to Resident #41's second toe and he provided report of the second toe injury to the on-coming nurse. On 8/8/18 at 5:56 PM, the DNS stated wounds with eschar and slough in the base would be considered unstageable. The DNS observed Resident #41's right ankle and right shin on the bed and stated her ankle and shin should be floated and off the bed. On 8/8/18 at 7:08 PM, RCM #1 stated she was unaware Resident #41 had an injury to the second toe on her right foot. RCM #1 stated Resident #41 refused a foot cradle on the bed and she could not provide documentation of this conversation occurring prior to 8/8/18. RCM #1 stated Resident #41 would refuse to float her right leg and she could not provide documentation of this prior to 8/8/18.

Based on observation, record review, and staff interview, it was determined the facility failed to provide adequate supervision to meet resident needs. This was true for 2 of 2 residents (#18 and #45) reviewed for supervision and accidents. Resident #18 was harmed when staff failed to provide sufficient supervision while the resident was in her room and she fell and sustained a femur (thigh bone) fracture. Resident #45 was harmed when she sustained a wrist fracture in her room when she fell from her bed. Findings include: 1. Resident #45 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #45's Fall Risk Assessments, dated 1/17/18, 4/14/18, and 7/19/18 documented she was at high risk for falls. An annual MDS assessment, dated 7/13/18, documented Resident #45 had a severe cognitive impairment and had experienced multiple non-injury falls. The MDS assessment documented Resident #45 did not use a bed alarm or chair alarm. The MDS assessment documented Resident #45 required extensive assistance of one to two staff members for all cares except eating. The care plan area addressing Resident #45's falls, initiated 12/12/17, documented she was at risk for falls related to a history of falls and generalized weakness. The care plan interventions were documented as follows: * Staff were to provide frequent checks on Resident #45 and keep her door ajar. * Staff were to keep her snacks at a higher level where Resident #45 could reach them easily. * Resident #45 was to wear non-skid foot wear at all times. * Resident #45's room was near the nurses' station for better visibility. * Staff were to answer Resident #45's call light promptly to help prevent falls. * Resident #45's call light was to be within reach at all times. Resident #45's clinical record documented she experienced 4 falls in her room between 4/14/18 and 6/4/18. Resident #45's I&A Reports documented the following: * An I&A Report, dated 4/14/18 at 10:45 PM, documented Resident #45 experienced an unwitnessed fall from her wheelchair. Resident #45 was attempting to transfer from her wheelchair into her bed and confirmed she hit her head. The I&A documented Resident #45 was trying to eat snacks and the facility moved her snacks to a higher drawer and she was educated to use her call light. The clinical management team review of the fall documented Resident #45 was cognitively impaired and the immediate actions of reminding the resident to utilize her call light and moving her call light were the appropriate interventions. Resident #45's care plan was updated on 4/20/18 to reflect this change. * An I&A Report, dated 4/30/18 at 11:15 AM, documented Resident #45 experienced an unwitnessed fall from bed. Resident #45 was found on her back with her head towards the door and her feet under the bed. The I&A documented Resident #45 was wearing normal socks and not non-skid foot wear. The I&A documented Resident #45 sustained an injury of a small bruise to her left hand and possibly one under her left eye. The I&A documented neurological assessments were initiated. The I&A documented Resident #45 was attempting to transfer from her bed into her wheelchair. The I&A documented the facility received orders for physical therapy to evaluate Resident #45 for education on strengthening related to transfers. The clinical management team review of the fall documented Resident #45 was cognitively impaired and Resident #45 transferred without the non-skid foot wear and she was refusing cares, was impulsive and did not wait for assistance at times. Resident #45's care plan was not updated after the 4/30/18 fall to reflect the change of refusal of cares and impulsiveness. * An I&A Report, dated 5/24/18 at 5:25 AM, documented Resident #45 experienced a fall from her wheelchair. The resident was attempting to transfer from her wheelchair into her bed. The I&A documented Resident #45 was wearing socks at the time of the fall. The I&A documented Resident #45 sustained an injury of small bruises to her left buttocks. The clinical management team review of the fall documented Resident #45 was cognitively impaired and Resident #45 was non-compliant with the care plan and attempted to self transfer without assistance. The recommendation of the team was to change the care plan to offer to assist Resident #45 to bed after meals. Resident #45's care plan was not updated after the 5/24/18 fall to reflect this change of assisting her to bed after meals. * An I&A Report, dated 6/4/18 at 2:30 PM, documented Resident #45 experienced an unwitnessed fall from her bed. Resident #45 was attempting to transfer from her bed into her wheelchair. The I&A documented Resident #45 was wearing not wearing any footwear at the time of the fall. The I&A documented Resident #45 sustained an injury of a right wrist fracture, bruising, and a skin tear. The clinical management team review of the fall documented Resident #45 was cognitively impaired and Resident #45 was probably attempting to self transfer and she was not wearing her non-skid foot wear. The care plan was updated to include keeping the door open to allow frequent checks. Resident #45's care plan was updated on 6/11/18 to reflect this change. On 8/6/18 at 5:24 PM, Resident #45 was observed calling out, Help, help, help. Three staff personnel walked by the room before someone stopped to see what Resident #45's needs were. On 8/8/18 from 8:50 AM- 9:00 AM, Resident #45 was observed calling out, Help, help, help, hi, hi. Resident #45's call light was activated. Resident #45 was assisted out of her bed at 9:00 AM by a staff member. On 8/9/18 at 4:11 PM, the DNS and RCM #1 stated Resident #45 was placed next to the nurses' station for increased supervision, her snacks were moved, and the open door policy initiated. RCM #1 stated Resident #45 preferred her belongings in a particular place and it was difficult for the facility to change things in her room. RCM #1 stated she hoped the care plan was updated with all the interventions following the falls. The facility failed to implement interventions, including increased supervision, to prevent Resident #45 from experiencing multiple falls in her room. 2. Resident #18 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE], documented Resident #18 was cognitively intact, had no history of falls, and required extensive assistance of two staff members for all cares except for eating and drinking. Resident #18's care plan initiated on 5/28/15, documented she was at risk for falls. The care plan approaches included a two-person Hoyer lift for all transfers, assessment for assistive devices, assessment of risk factors, and Resident #18's use of wheelchair for mobility with the assistance of one person. Resident #18's care plan initiated on 10/9/17, documented she was at risk for impaired vision due to diabetes mellitus. The care plan directed staff to report any unusual visual disturbances, blurred vision, halos, and double vision. The 10/9/17 care plan did not state Resident #18's commonly used items were to be placed within her reach. An I&A Report, documented Resident #18 had an unwitnessed fall from bed at 6:30 AM on 7/14/18. The report documented initial nurse in room foun(d) rsdt (resident) on the floor with 1 leg still up on the side of the bed tangled in a blanket . Activity engaged in at the time of the fall was documented as Looking for call light or reaching for call light, rsdt (resident) stated both. Call light was attached to her covers per usual. A revised care plan dated 7/14/18, documented Resident #18 had a fall from bed. Approaches included in the care plan were to place a fall mat on the floor while Resident #18 was in bed, a bolster to be placed on the bed for safety per Resident #18's request, and staff were to encourage Resident #18 to keep her bed in the lowest position. A Nursing Note, dated 7/14/18 at 9:28 AM, documented licensed nurse entered Resident #18's room and observed her lying face down on the floor next to her bed. Resident #18's head was on the floor and her chest and lower extremities were on top of the metal legs of her bedside table. The Nursing Note documented further assessment of Resident #18's legs, knees and ribs found they were without deformities and there were no changes to her normal range of motion. A Nursing Note, dated 7/14/18 at 5:48 PM, documented Resident #18's left knee was swollen and painful to touch with no obvious deformity. Resident #18 also complained of pain in her ribs. A physician order [REDACTED].#18's chest and left lower extremity. A family representative wanted Resident #18 sent to the hospital, but Resident #18 elected not to go to the emergency room . Resident #18 was aware her x-rays would be taken the following Monday. Resident #18's x-ray results, dated 7/16/18, documented an acute impacted supracondylar femur (thigh bone) fracture and a normal left shoulder. A Physician Note, dated 7/20/18, documented I contacted (name of physician) for phone consult and outlined my opinion that pt (patient) is not an operable candidate. We will place her in L (left) knee brace in extension . A Physical Therapy Evaluation and Treatment note, dated 7/19/18, documented fit resident with a functional brace for supercondylar fracture on left . On 8/8/18 at 9:08 AM, Resident #18 said she fell off her bed because she was trying to reach her call light. When asked where call light was, Resident #18 said over there, pointing to her bed side table to the right side of her bed. Resident #18 said it was early in the morning when it happened. She said she had felt cold and needed an extra blanket and could not reach her call light. On 8/8/18 at 2:55 PM, Resident #18 said she smoked cigarettes 2-3 times per day had not smoked for weeks now because her left leg hurts whenever she moves. On 8/8/18 at 5:35 PM, a surveyor entered Resident #18's room. Resident #18 was observed in bed, her bed was slightly raised and on her right side was the overbed table with two glasses of a juice. Resident #18 asked the surveyor to push her overbed table closer to her so she reach her drink. The surveyor asked Resident #18 how she would ask for help if the surveyor was not in her room. Resident #18 then pushed her call light as a response. On 8/9/18 at 10:00 AM, the Maintenance Director said he helped to deliver drinks to the residents the day before. He said he knew Resident #18 and forgot to ask her if she needed anything else when he put the glasses of juice on her overbed table. The Maintenance Director said he should have made sure Resident #18 could reach the juice before he left her room. On 8/9/18 at 2:47 PM, RCM #3 said Resident #18 rolled out of her bed while trying to reach her call light. RCM #3 said she was told by the nurse that Resident #18's call light was always within reach of the resident. RCM #3 said staff should ensure Resident #18's call light, television remote control, drinks, and other commonly used items were within her reach. RCM #3 said staff were to ask Resident #18 what else she needs before leaving her room.

Based on observation, staff and resident interview, and review of records, it was determined the facility failed to ensure physicians' orders were followed as directed to effectively manage residents' pain. This was true for 2 of 2 (#18 and #41) residents sampled for pain. Resident #18 and Resident #41 were harmed when they experienced increased pain during cares and a dressing changes. Findings include: 1. Resident #41 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission MDS assessment, dated 7/13/18, documented Resident #41 had severe cognitive impairment. The MDS assessment documented she required extensive assistance from 1 to 2 staff members for all cares. The MDS assessment documented she experienced frequent pain and her pain was rated at an 8 out of 10. The care plan area addressing Resident #41's pain, initiated 7/25/18, documented staff were to administer medications as ordered and anticipate Resident #41's need for pain relief and respond to her complaints of pain. Resident #41's physician's orders [REDACTED]. Resident #41 did not have orders for scheduled pain medications or daily pain monitoring. A Care Conference Report, dated 7/13/18, documented Resident #41 refused to get out of bed and she was admitted with multiple pressure ulcers and poor skin integrity. The Weekly Skin Alteration Reports documented the following: * Weekly Skin Alteration Reports, dated 7/6/18, 7/10/18, 7/17/18, 7/20/18, 7/27/18, and 8/3/18, documented Resident #41 had a stage three pressure ulcer on her outside right ankle, first observed upon admit. * Weekly Skin Alteration Reports, dated 7/6/18, 7/10/18, 7/17/18, 7/20/18, 7/27/18, and 8/3/18, documented Resident #41 had an arterial wound on her right outer shin with black area, first observed upon admit. Resident #41's 7/9/18 through 8/8/18 MAR indicated [REDACTED]. Examples include: * [MEDICATION NAME] was not administered from 7/14/18 through 7/22/18, 7/27/18 through 7/29/18, 8/4/18, and 8/5/18. * Her weight was not assessed from 7/7/18 through 7/9/18, 7/11/18 through 7/16/18, 7/20/18 through 7/24/18, and 7/27/18 through 8/8/18. * Bordered foam dressing to the mid and upper back, right ankle, and right shin was not changed on 7/23/18, 7/28/18, 7/29/19, 8/1/18, 8/3/18, 8/4/18 and 8/6/18. * Her daily measurements of her bilateral ankles, bilateral calves, and bilateral insteps were not assessed on 7/11/18, 7/12/18, 7/16/18, 7/17/18, 7/20/18 through 7/24/18, and 7/26/18 through 8/8/18. * Skin moisturizer was not applied on 7/14/18, 7/16/18, 7/20/18, 7/21/18, 7/22/18, 7/27/18, 7/28/18, 7/29/18, 8/3/18, 8/4/18, and 8/5/18. * Skin moisturizer was applied once a day, instead of twice as a day as ordered on [DATE], 7/17/18, 7/15/18 7/23/18, 7/24/18 7/30/18, 7/31/18 and 8/6/18. On 8/6/18 at 5:47 PM, Resident #41 was observed laying in bed with a pillow under her back on her left-side. On 8/7/18 from 9:47 AM through 4:11 PM, Resident # 41 was observed on her back with a pillow under her right arm and her legs flush on the bed. Resident #41's right ankle and right calf was positioned flat against the mattress. On 8/7/18 at 10:42 AM, Resident #41's right leg was observed with a bandage on the outside of her right ankle and an ACE bandage on her right shin. CNA #1 and CNA #2 were observed assisting Resident #41 with changing her incontinence brief. CNA #1 removed the pillows under Resident #41's right arm and she cried out, Ow, ow, ow, ow, ow, ow. CNA #1 and CNA #2 rolled Resident #41 onto her left-side and Resident #41 said, Ow, ow, ohh God, ow, ow. CNA #1 stated sorry and he knew it was painful. Resident #41 stated, Ow, ow, ow, oh, oh, oh my left leg, you are pulling on my hip. The CNAs rolled Resident #41 onto her back and then onto her right-side. She continued to cry and say Ow, ow, ow, ow, ow, ohh, ohh, my arm, could you lift you have a hand on my arm, oh, oh, oh, oh, my arm, oh, oh, oh, oh, could you lift your arm, ow, ow, ow! The CNAs completed changing Resident #41's incontinence brief and positioned Resident #41 up higher in bed. During the process Resident #41 continued to cry out, Oh, oh, oh. CNA #2 was observed placing a pillow under her right side and she continued to express cries of pain. CNA #1 and #2 stated they had to replace the pillow under her back and she stated she was in too much pain to allow then to apply the pillow behind her back and to please wait a while. On 8/7/18 at 12:11 PM, Resident #41 stated she was not always provided pain medications prior to dressing changes and when she was not provided the medications she would refuse due to pain. Resident #41 stated when she was provided pain medications the dressing changes could be managed. On 8/8/18 from 8:37 AM to 5:56 PM Resident #41's right ankle and her right calf were observed positioned flat against the mattress. On 8/8/18 at 1:12 PM, Resident #41 was observed during a dressing change to her right shin. Resident #41's leg was positioned back on the mattress after LPN #4 completed a dressing change. Resident #41 cried out during the dressing change saying, Ow. On 8/8/18 at 1:25 PM, Resident #41 was observed crying and complaining her right arm hurt really bad. Resident #41 stated her pain was rated at an 8 out of 10. On 8/8/18 at 1:33 PM, LPN #2 was called for assistance and LPN #2 was observed attempting to reposition Resident #41's pillow under her right arm. Resident #41 started crying and stated, I do not mean to cry, but it hurt really bad. On 8/8/18 at 1:34 PM, LPN #2 provided Resident #41 with a pain pill. On 8/8/18 at 5:45 PM, DNS stated the facility monitored residents for the first 72 hours for pain and then determine the residents pain control plan based on the 72 hour pain assessments. The DNS stated nurses should be monitoring residents for the effectiveness of the pain control plan and notify the physician if new pain presents. The DNS stated the facility also assessed residents quarterly for changes in pain to determine the effectiveness of the pain medications. The DNS stated she was not aware of Resident #41's refusals of treatments and medications due to pain and she was not aware of her increased pain. The DNS stated she could not see what non-pharmacological interventions were being utilized for Resident #41. Resident #41's clinical record did not contain documentation of notification to the physician when she continually refused medications and treatments due to pain. The DNS stated the staff should have notified the physician about Resident #41's increased pain and increased refusals. 2. Resident #18 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. An annual MDS assessment, dated 5/27/18, documented Resident #18 was cognitively intact, experienced occasional pain, received routine and PRN (as necessary) pain medications. The MDS assessment also documented Resident #18's pain did not limit her day to day activities. Resident #18's (MONTH) (YEAR) recapitulated physician's orders [REDACTED].>*Bio-freeze or generic equivalent PRN topically for pain, ordered 9/27/17. *[MEDICATION NAME] 75 mcg/hour, every 72 hours, ordered 7/16/17. *[MEDICATION NAME] Adhesive patch medicated, 5%: 1 patch topical once a day, ordered 7/22/2017, *[MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) 5/325 mg tablet, tablet PRN every 6 hours, ordered 6/20/16. Resident #18's care plan documented Resident #18 had left shoulder pain as evidenced by Resident #18's verbalization of pain. Interventions included in the care plan were: * Resident #18 will ask for pain medication for breakthrough pain * Pain assessment on admission, and as necessary * Monitor pain until effective pain management plan is established * Position resident for comfort Non-pharmacological interventions were not included in the care plan for Resident #18's shoulder pain. An I&A Report, dated 7/14/18, documented Resident #14 fell out of bed while trying to reach her call light. Resident #18's revised care plan, dated 7/14/18, documented Resident #18 had a fall from bed and she was at risk for falls. Interventions included in the care plan were to place a fall mat on the floor while Resident #18 was in bed, a bolster to be placed on the bed for safety per Resident #18's request, and staff were to encourage Resident #18 to keep her bed in the lowest position. The care plan did not address the left leg pain she was experiencing due to the thigh fracture. A Physical Therapy Evaluation and Treatment note, dated 7/19/18, documented fit resident with a functional brace for supercondylar fracture on left . A 7/16/18, X-ray result, documented a fracture involving Resident #18's left supracondylar femur (thigh) without displacement. A Physician Notes, dated 7/20/18, documented I contacted (physician name) for phone consult and outlined my opinion that pt (patient) is not an operable candidate. We will place her in L (left) knee brace extension. Pain Meds (medication) modified see orders. A Physician order [REDACTED]. * Discontinue [MEDICATION NAME] 5/325 mg tablet, resident has high level of pain medication (PRN) for LLE fracture, * [MEDICATION NAME] 10/325 mg tablet, PRN every four hours, one tablet for 1-5 pain, two tablets for 6-10 pain, * (MONTH) have floor mat next to bed for safety. Resident #18's (MONTH) (YEAR) PRN Medication Administration Pain Management Flow Sheet documented Resident #18 received one tablet of [MEDICATION NAME] 10/325 mg, instead of two tablets as ordered, for a pain rating of 6-10. Examples include: * On 7/20/18 at 6:11 PM, Resident #18 rated her pain at 8 and received one tablet of [MEDICATION NAME] 10/325 mg. Resident #18's pain was reassessed and rated her pain at 3. * On 7/23/18 at 6:47 AM, Resident #18 rated her pain at 9 and received one tablet of [MEDICATION NAME] 10/325 mg. Resident #18's pain was reassessed and rated her pain at 4. *On 7/23/18 at 11:05 AM, Resident #18 rated her pain at 9 and received one tablet of [MEDICATION NAME] 10/325 mg. Resident #18's pain was reassessed and rated her pain at 2. *On 7/24/18 at 11:24 AM, Resident #18 rated her pain at 7 and received one tablet of [MEDICATION NAME] 10/325 mg. The resident's pain was reassessed and rated her pain at 2. *On 7/25/18 at 9:52 AM, Resident #18 rated her pain at 9 and received one tablet of [MEDICATION NAME] 10/325 mg. The resident's pain was reassessed and rated her pain at 2. *On 7/25/18 at 3:46 PM, Resident #18 rated her pain at 10 and received one tablet of [MEDICATION NAME] 10/325 mg. The resident's pain was reassessed and rated her pain at 1. *On 7/27/18 at 4:56 AM, Resident #18 rated her pain at 7 and received one tablet of [MEDICATION NAME] 10/325 mg. The resident's pain was reassessed and rated her pain at 4. A Nursing Note, dated 7/24/18 at 10:27 AM, documented Resident #18 showed aggressive behavior towards staff during nursing cares. She refused to be touched or moved afraid it would cause her pain. A Nursing Note, dated 7/31/18 at 6:16 AM, documented Resident #18 was tearful when turned in her bed to change her adult diaper. A Nursing Note, dated 7/31/18 at 1:57 PM, documented .resident is only allowing staff to provide cares 1 x shift, and she is not allowing them to roll her over .Resident has extreme anxiety when attempting to look at areas . On 8/7/18 at 3:41 PM, a surveyor entered Resident #18's room, where two CNAs and RN were observed providing nursing cares to Resident #18. The surveyor asked permission to observe the staff while they provide nursing cares to Resident #18. The RN asked Resident #18 and she said No. As the surveyor was leaving the room, the surveyor heard Resident #18 saying in a loud voice no no no my leg my leg. On 8/8/18 at 9:48 PM, CNA #2, who worked as a RNA, said Resident #18 had not received restorative nursing services since she fell because Resident #18 always refused due to severe pain. On 8/8/18 at 2:55 PM, Resident #18 said she smoked cigarettes 2-3 times per day but had not smoked for weeks now because her left leg hurt whenever she moved. On 8/9/18 at 10:12 AM, CNA #4 and CNA #6 were providing nursing cares to Resident #18. The CNAs changed Resident #18's soiled brief. While the two CNAs assisted Resident #18 with cares and rolled her from side to side she moaned and continued to moan throughout the process. Resident #18 was heard saying loudly no no no, don't don't don't as she was rolled from side to side. On 8/9/18 at 2:11 PM, RCM #3 confirmed Resident #18 pain medications were not consistently administered as ordered. She said it was a concern since Resident #18 was always in pain. RCM #3 said she was not sure whether the nurse had recognized the change in Resident #18's pain medication. RCM #3 said nurses should asked the residents at least once every shift if they are in pain or not. RCM #3 then looked at the nursing notes and said she did not find documentation regarding the reason Resident #18 received one tablet of [MEDICATION NAME] 10/325 for pain scale of greater than 5. Resident #18 was harmed when she did not receive the right amount of pain medications ordered. She refused to smoke and participate her restorative nursing program because of the pain she experienced.

Based on observation, record review, resident and staff interviews, and policy review, it was determined the facility failed to ensure: *Pressure ulcers did not develop, *Pressure ulcers did not redevelop after they were healed, *Interventions were implemented after pressure ulcers developed, *Assessments of pressure ulcers were completed timely, and *A pressure ulcer was identified. This was true for 2 of 4 (#4 and #6) residents sampled for pressure ulcers. Resident #6 was harmed when he developed two Stage II pressure ulcers, a Stage II pressure ulcer redeveloped, interventions were not implemented in a timely manner, and assessments were not completed in a timely manner. Resident #4 was at risk for harm related to the facility's failure to assess a stage I pressure ulcer. Findings include: The facility's Skin at Risk/Skin Breakdown policy, dated January 2016, documented nursing staff will: *Notify the physician and obtain treatment orders for new skin impairments, *Implement interventions and document interventions on the resident's care plan, and *Assess, measure and document weekly on the Skin Grid. 1. Resident #6 was readmitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #6's 9/28/12 physician's x-ray report documented, Shrapnel is present in the soft tissues overlying the left obturator foramen and stump. Resident #6's 10/22/12 physician's progress note documented: -This has come back showing some shrapnel in the obturator foramen on the left side. There is no evidence of any shrapnel in the sacral gluteal area on the right side. -Look into a tilting wheelchair. This would be very favorable in terms of getting him off of this pressure area .cannot off-weight when he is up in the chair and does not want to spend all day in the bed. Resident #6's current care plan documented on 10/9/12 a Risk for Skin breakdown due to mobility limitations and a history of shrapnel in the right buttock. The care plan documented the following interventions: *10/9/12-Utilize air mattress on bed, monitor right buttock where shrapnel exits, and Roho cushion to wheelchair, and *11/29/16-Resident is noncompliant with orders and encouragement to lay down between meals and staff to continue to encourage resident to off load. Resident #6's 5/17/16 and 8/17/16 quarterly, and 11/12/16 annual MDS assessments documented, he did not have an unhealed pressure ulcer and required two-person extensive assistance for transfers. Resident #6's 11/12/16 annual MDS assessment documented he was cognitively intact, with a BIMS of 14 and that he did not reject cares. Resident #6's 11/29/16 Braden Scale assessment documented the resident was chairfast and had very limited mobility. Resident #6's Skin Grid documented the resident had a Stage II pressure ulcer on his right buttock which developed on 6/17/16 and was healed on 8/9/16. Resident #6's December 2016 TAR documented an order, dated 6/21/16, to apply [MEDICATION NAME] cream and cover with [MEDICATION NAME] dressing to the right buttock every 3 days. The TAR documented the treatments had been completed. Resident #6's Skin Grid documented on 12/27/16 the resident developed three Stage II pressure ulcers to the right and left buttocks. -Wound #1-Right buttock: *12/27/16- Stage II, 5.0 (length) X 2.5 (width) X 0.1 (depth) cm, red/pink, *1/8/17- 5.5 X 4.0 X 0.2 cm, Note: This assessment was completed 12 days after the pressure ulcer was discovered. *1/19/17- 4.0 X 3.0 X 0.1 cm, bloody drainage, Note: This assessment was completed 11 days after the previous assessment. *1/21/17- 5.75 X 3.5 X 0.1 cm, slowly healing. There were no more documented assessments of the wound until 2/9/17. -Wound #2-Left buttock: *12/27/16- Stage II, 5.5 X 5.5 X 0.3 cm, red/pink, *1/8/16- 5.5 X 2.5 cm, This assessment was completed 12 days after the pressure ulcer was discovered. *1/19/17- 4.5 X 2.0, bloody drainage, This assessment was completed 11 days after the previous assessment. *1/27/17- 4.0 X 0.5, almost closed. There were no more documented assessments of the wound until 2/9/17. -Wound #3-Left buttock: *12/27/16- Stage II, 1 X 1 X 0.3 cm, pink/red, *1/8/17- 2.75 X 1.5 X 0.2, The assessment was completed 12 days after the pressure ulcer was discovered. *1/19/17- 2.0 X 1.0 cm, small amount of blood, This assessment was completed 11 days after the previous assessment. *1/21/17- 0.5 X 0.5 cm, almost closed. There were no more documented assessments of the wound until 2/9/17. Resident #6's care plan did not include new interventions after the three pressure ulcers developed. Resident #6's progress notes documented, *1/3/17- Wounds to both buttocks, cleansed, [MEDICATION NAME] applied and non-adhere foam dr(essin)g to both. No order was found for treatment of [REDACTED]. *1/4/17- Wounds to R/L (right/left) buttocks, cleansed, applied [MEDICATION NAME] and non-adhesive foam. Resident #6's fax to the physician dated 1/5/16, documented: Both of (Resident #6)'s butt cheeks are breaking down again. I have orders for his Right Buttock, but not the left, and the order I have is for [MEDICATION NAME] and to cover with [MEDICATION NAME]. Anything with even a slight adhesive is pulling skin off. Can we have an order as stated below instead? The physician's orders [REDACTED]. The physician documented, OK. The facility nurse order review section was signed on 1/8/17. Resident #6's January and February 2017 TARs document a 1/8/17 order, Buttock Wounds: Gently clean with saline, pat dry, apply [MEDICATION NAME] and cover with a non-adhesive foam dressing daily and PRN until resolved. On 2/7/17 at 8:45 am and 10:55 am, on 28/8/17 at 8:50 am and 1:40 pm, and on 2/9/17 at 8:40 am, Resident #6 was observed in his room and in his wheelchair with a Roho cushion. On 2/8/17 at 8:50 am, Resident #6 was in his wheelchair in his room and said staff did not ask him to lay down after breakfast and said he might lay down if they had asked him. He said he did not remember if staff had ever educated him about the importance of laying down between meals. At 4:35 pm, Resident #6 was in his wheelchair at the dining room table and said he had been up in his wheelchair all day and he did not remember if staff ever offered to lay him down that day. He said since dinner was coming up, there was no reason to lay down until after dinner. On 2/9/17 at 8:45 am, LN #7 said Resident #6 did not always want to lay down when asked, but was not sure if the refusals were documented. On 2/9/17 at 2:30 pm, a surveyor and LN #3 observed Resident #6's pressure ulcers. LN #3 said wound #1 to the right buttock measured 5.5 (length) X 3.0 (width) cm and appeared bloody. LN #3 said wound #2 to the left buttock measured 1.5 X 1 cm with a pink clean wound bed. LN #3 said wound #3 to the left buttock measured 0.5 X 0.5 cm with a pink clean wound bed. Resident #6's 2/9/17 Skin Grid documented wound #1 measured 5.0 X 3.0 cm and wound #3 measured 0.3 X 0.3 cm. On 2/9/17 at 3:35 pm, the DNS and RCM #2, with the Regional Support Nurse present, said the pressure ulcers most likely developed because Resident #6 was up in his wheelchair too long and he did not always like to lay down. The DNS said the care plan did not direct staff to educate the resident if he refused to lay down and Resident #6's medical record did not document where education to the resident had been provided and could not find documentation of Resident #6's refusals. The Regional Support Nurse asked RCM #2 if the facility had implemented a deviation of care for Resident #6's refusals and RCM #2 said she had not. RCM #2 said the physician was not notified of the pressure ulcers until the fax on 1/5/17. The DNS said there were no interventions implemented after the breakdown until the 1/8/17 order for wound dressings was initiated and no other interventions were put into place. RCM #2 said the last measurement of the pressure ulcers was completed on 1/21/17 and said progress notes documented the wounds were improving, but the notes did not include characteristics of the ulcers. The DNS said the assessments were not completed timely to make sure the ulcers were healing properly or if new interventions needed to be tried. On 2/9/17 at 5:30 pm, the DNS provided the surveyor a document titled Informed Consent Identifying Risks For Deviation In The Recommended Plan Of Care which was signed by Resident #6 and dated 11/5/12. The consent documented Resident #6's buttock wound might not resolve and could worsen if he did not lay down between meals. The DNS said the form had not been updated or revised because nothing had changed since then. The DNS said Resident #6 redeveloped a Stage II pressure ulcer to the right buttock. The facility failed to ensure Resident #6 did not develop two Stage II pressure ulcers and did not redevelop a Stage II pressure ulcer. Resident #6 had not been educated on the importance to lay down to relieve pressure. Interventions were not implemented in a timely manner after the pressure ulcers developed and assessments were not completed timely to determine if the plan of care needed to be altered. 2. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #4's quarterly MDS assessment, dated 12/18/16, a BIMS score of 7 out of a possible score of 15, indicating she was severely cognitively impaired. Resident #4 required extensive assistance of one staff person with bed mobility, transfer, dressing, toilet use and personal hygiene. The assessment documented Resident #4 was, at risk for pressure ulcers. No unhealed pressure sores were identified. During the tour with the SDC on 2/6/2017 at 2:10 pm, Resident #4 was observed to have labored breathing and was non-responsive to the SDC. When queried regarding the care and services being provided to Resident #4, the SDC responded that Resident #4 declined. I don't know what's being done for her. Her mouth is dry and we've been trying to keep it moist. Resident #4 was observed on 2/7/17 at 10:30 am during incontinence care provided by CNA #3 and CNA #4. She was observed to have redness and excoriation from the anus expanding 2 inches to both buttocks and covering all areas within the 2 inches. At the time of the observation CNAs #3, #4 and #5, who were responsible for providing care for Resident #4, stated they did not have specific care instructions for Resident #4. They said they were turning and repositioning her every 2 hours. According to the CNAs, they were not aware of the excoriated areas to Resident #4's buttock. Resident #4's Skin Grid for All 'Other' Skin Problems did not include documentation of the reddened and excoriated anal area and buttocks. During an interview with LN #3 at 3:30 pm, LN #3 stated, There are no other skin sheets for her. She does not have a pressure ulcer. We are not putting anything on her buttocks. There is nothing on the TAR. Resident #4's current Care Plan did not include documentation of the reddened and excoriated anal area and buttocks. An Approach with the start date 12/11/12 documented, Report any signs of skin breakdown (sore, tender, red or broker areas). Resident #4's Physician order [REDACTED]. The Report did not include an order for [REDACTED]. On 2/8/17 at 2:50 pm, Resident #4's skin was observed in the presence of the DNS. There was white cream covering the reddened excoriation on Resident #4's anal area and buttocks. The DNS stated she did not know what the white cream was as she did not put it on. The DNS said Resident #4's anal and buttocks area was getting better. At 4:50 pm on 2/9/17, LN #3 was asked about the white cream on Resident #4's reddened and excoriated anal area and buttocks. She stated she had looked at the area with a flashlight on 2/8/17, and there was no reddened area or excoriation. A Progress Note, dated 2/8/17 at 10:42 by LN #3, documented Resident #4's skin was intact no open or red areas were noted to the buttocks or peri area. At 5:00 pm on 2/9/17 the DNS said she did not know the physician was notified of Resident #4's the red and excoriated area or if orders were received to treat the area. On 2/9/17 5:20 pm, the DNS provided a copy of a request for a physician's orders [REDACTED]. The facility's Policy and Procedure on Skin at Risk/Skin Breakdown, dated 1/2016, documented, A full body skin audit will be completed weekly by the LN. Completion of the skin audit will be documented on the Treatment Administration Record (TAR) with their initials .

Based on staff interview, accident report review and record review, it was determined the facility failed to ensure assistive devices were utilized as care planned for for 1 of 13 sampled residents (#6). This resulted in harm to Resident #6 when she sustained a fracture to the left femur. Findings included: Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident's quarterly MDS assessment, dated 4/13/10, coded: * Severely impaired cognitive skills for daily decision-making * Total assistance of two plus persons for transfer, bed mobility, dressing and toilet use * No limitation of ROM on the neck * No limitation on the foot - including ankle or toes * No recent fractures were documented The resident's most recent quarterly MDS assessment, dated 7/14/10, coded: * Severely impaired cognitive skills for daily decision-making * Total assistance of two plus persons for transfer, bed mobility, dressing and toilet use * Sustained a fracture in the past 180 days * Limitation of ROM on both sides of the neck * Limitation to ROM of one foot- including ankle or toes Note: ROM had decreased after the fracture, on the foot and neck. Resident #6's Plan of Care, not dated, documented in the problem section the resident required total assistance with ADL's, the goal was for Resident #6 to "...remain free from injury requiring out of facility medical intervention." The "Approach" section, dated 10/14/07, stated "Provide 2 person assist with all bed mobility, incontinence care, and transfers." Progress Notes for Resident #6, dated 4/30/10, documented a CNA reported Resident #6 displayed signs and symptoms of pain "with movement of left leg. Assessment of left leg reveals no obvious deformity, no areas of localized redness, with PROM (passive range of motion) resident grimaces and clasps hands together on her stomach. Resident has a HX (history) of FX (fracture) to lower legs." The physician was faxed the results of the assessment. Progress Notes, dated 5/3/10, documented orders were received from Resident #6's physician to observe the resident and use a warm compression. A second entry, on 5/3/10, documented an assessment of the left lower leg revealed "slight lateral rotation of ankle and foot from midline of knee, semi-hard knot of tissue to upper calf, increased pain with light PROM. Resident grimaced with the slightest dorsiflexion and elevation of her ankle." The physician was notified of the results of the assessment. On 5/3/10 an order to x-ray the left leg was received from the physician. The Progress Notes documented Resident #6 returned to the facility, after the x-ray on 5/4/10, with a new order for a knee immobilizer to the left leg. An "Incident Questionnaire," dated 5/4/10, documented Resident #6 had signs and symptoms of increased pain with PROM to her left leg. Her physician was notified and ordered the left leg and hip to be x-rayed. The x-ray documented a fracture to the left femur. Page 2 of the Incident Questionnaire documented the plan for prevention was an "investigation." The multi-disciplinary incident review stated "Suspect that transfer of rsdt (resident) occurred with less than optimal staff (against CP (Care Plan)). In service all staff." When asked what "less than optimal staff" meant, on 10/20/10 at 2:50 p.m., the Administrator and DON stated the CP was not implemented as it documented Resident #6 was to be transferred with 2 staff using a mechanical lift. The Administrator stated CNA #3 had previously been warned about transferring residents. A copy of the previous warnings was requested at that time. An "Associate Memorandum" dated 3/24/10 documented CNA #3 had been warned about using the mechanical lift independently. The number of prior written warnings was not included. However, the memorandum documented "There are reports of you using mechanical lifts by yourself. About 2 weeks ago I saw you do this and explained the rule to you.....Over this weekend, it was noted that you were doing this and your nurse supervisor spoke to you about it." The "Reportable Incident Form" (RIF) documented an "Injury of Unknown Origin " was reported on 5/4/10 at 3:00 p.m. The RIF documented increased pain was reported for Resident #6 on 5/3/10, an assessment was completed and documented a "knot" was noted on the calf of Resident #6's leg. An x-ray documented a fracture of the femur of the left leg. The RIF documented in the "Summary of Investigation" none of the staff interviewed stated they assisted a co-worker to transfer Resident #6 back to bed during "the couple days prior" to her first reports of pain. A summary of the staff interviews stated CNA #3 ( no longer employed at the facility as of 5/3/10)" kept to herself" or "does her own thing." Also documented in the summary was, "While there is no decisive conclusion, it seems as if this CNA transferred this resident alone, using a stand pivot. The aide had a history for this, and while this rsdt (resident) was known to be fragile and should not be transferred in this style, she could stand. This aide is no longer employed here." The Administrator and DON were interviewed, on 10/21/10 at 8:55 a.m. When asked why CNA #3 was not interviewed regarding transferring Resident #6 by herself, the Administrator stated she, "could not answer" the question. When asked which resident/residents were transferred incorrectly in the "Associate Memorandum" the Administrator and DON were unable to identify the residents. Resident #6 was harmed when her CP was not implemented and she sustained a broken left femur.