Every finding on record at Pine View Care Center

Based on observation, interview, and record review, the facility did not ensure a resident area remained at a safe, comfortable, and home-like temperature for 4 of 4 residents (R) (R1, R2, R3, R4) reviewed. On 07/16/26, the facility's Heating, Ventilation, and Air Conditioning (HVAC) cooling system on the 100 unit where R1, R3, R4 resided, and 300 unit where R2 resided stopped working which resulted in room temperatures that were above 81 degrees Fahrenheit (F). Common areas throughout the building exceeded 81 degrees F.This is evidenced by: On 07/16/26 at 10:45 AM, the outside temperature was 82 degrees F with a feel like temperature of 85 degrees F. On 7/16/26 at 9:12 AM an air quality alert was in effect for [NAME] County until noon on 7/17/26 according to La [NAME] Wisconsin National Weather Service. On 07/16/2026 at 10:49 AM, Nursing Home Administrator (NHA) A and Director of Nursing (DON) B entered the conference room for entrance conference. NHA A had the corporate Chief Nursing Officer (CNO) D on speaker phone. CNO D explained that there was a tip placed on social media about this facility being hot and the A/C not working. CNO D explained 2 years ago Occupational Safety and Health Administration (OSHA) came into the building when it was hot and provided the facility with 'Hot Weather Mitigation' recommendations. CNO D explained how the facility has implemented these strategies by: Educating all staff by putting up heat exhaustion posters with the punch clock. Hydration stations are provided throughout the building. Placed fans throughout the building. Checking ambient temperatures. Small portable A/C units in commons areas for residents to sit at. Call placed out to [NAME] Heating Ventilation and Air conditioning (HVAC). Personal frozen treats are available for staff and residents. Review of AccuWeather historical daily high temperatures for Black River Falls, Wisconsin: ~07/05/26 84 degrees F ~07/06/26 87 degrees F ~07/07/26 86 degrees F ~07/08/26 86 degrees F ~07/09/26 85 degrees F ~07/10/26 85 degrees F ~07/11/26 88 degrees F ~07/12/26 90 degrees F ~07/13/26 92 degrees F ~07/14/26 94 degrees F ~07/15/26 96 degrees F ~07/16/26 92 degrees F On 07/16/26 at 3:49 PM, the Weather Channel temperature for Black River Falls was 88 degrees F with a feel like temperature of 95 degrees F. Example 1 R2 was admitted to the facility on [DATE] with current diagnoses of dementia, chronic kidney disease stage 3, localized edema, and Parkinson's disease. R2's nursing progress notes included the following: 07/08/26 at 11:08 AM, Legs continue to swell, [R2] takes furosemide every other day and maintains the swelling but has not decreased in size of his legs and feet. Continues to not use his Tubi grips or takes them off but the unit remains in the upper 80's because of the temperature so has been hotter the last couple of weeks. 07/13/26 at 12:00 AM, Note: resident sat in the dining room after supper for a while when resident was trying to get up to use the restroom, resident had appeared weak, he needed 2 staff to help him, writer and CNA (Certified Nursing Assistant) [Name] used the wheelchair to get him to the restroom, resident was able to walk baseline back to his bed from the restroom. 07/15/26 at 1:37 PM, Hot in the MCU (Memory Care Unit), [R2] has been stripping off his shirt and pants and walking in his brief so has had to be redirected back to his room. Legs continue to be swollen but again due to the heat he has been taking off his Tubi grips.[R2] has taken more time eating his food and commented yesterday that staff try to hurry him to eat but he has taken to sitting at the table talking to himself and not eating his food so at times only consumes 50%. On 07/16/26 at 2:38 PM, Surveyor checked the temperature in R2's room. The temperature at the wall and at R2's pillow registered at 85.8 Fahrenheit (F). A ceiling vent in R2's room was blowing hot air the temperature at the vent registered at 89.7 degrees F. On 07/16/26 at 2:44 PM, Surveyor interviewed Licensed Practical Nurse (LPN) J asking if R2 continues to take their clothes off. LPN J stated R2 has been the only resident taking their clothes off and this could be related to the heat in the building and R2 needing to use the bathroom. Surveyor asked if staff had taken temperatures of resident areas. LPN J stated there is thermometer in the medication room which reads 88.0 F. LPN J stated there is not a thermometer in the main area of the MCU (Memory Care Unit). LPN J stated it has been really, hot in the facility for the last week. On 07/16/26 at 2:56 PM, Surveyor in conjunction with Maintenance C, obtained temperatures in the building. R2's room wall: Maintenance C's temperature 83.3 F. Surveyor's temperature 86.8 F. R2's ceiling vent: Maintenance C's temperature 87.8 F. Surveyor's temperature 89.8 F. Example 2 R4 was admitted on [DATE] with current diagnoses of morbid obesity, lymphedema, and asthma. Annual MDS (Minimum Data Set) assessment dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 15/15, meaning intact cognition. On 07/16/26 at 12:30 PM, Surveyor interviewed R4 about activities participation and if R4 noted less meal intake related specific to the heat. R4 denied that the heat changed their activity participation or meal intake. R4 shared it was hot and uncomfortable in the facility. On 07/16/26 at 12:34 PM, Surveyor obtained temperatures in R4's room. The wall by the head bed and bed temperatures were 89.1 F. Example 3 R1 was admitted to the facility on [DATE] with current diagnoses of type 2 diabetes mellitus and muscle weakness. Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14/15, meaning intact cognition. On 07/16/26 at 12:03 PM, Surveyor interviewed R1, in the dining room, about the temperatures in the facility. R1 stated it is a sauna in the facility and in R1's room. The other night a Certified Nursing Assistant (CNA) brought in a fan. The fan does not oscillate and only has a low speed. It has been hot here for a while, and it was said that the AC is 30-[AGE] years old. The staff give us ice water, popsicles, and juices for hydration. Early mornings it cools off a little bit. It has been hot in the facility for a long time. Surveyor asked R1 if R1 had been sick from the heat or had a decrease in appetite. R1 stated not being sick and they feel they are drinking more due to the heat. R1 stated the heat was terrible. On 07/16/26 at 12:10 PM, Surveyor noted the wall thermostat in the dining room with a temperature reading at 90 F. On 07/16/26 at 12:14 PM, Surveyor checked temperatures in R1's room. R1 had a box fan on a dresser facing R1's head of bed. Surveyor measured the wall temperature next to the head of bed which registered at 88.8 F. R1's bed pillow temperature registered at 89.0 F. On 07/16/26 at 3:05 PM, Surveyor interviewed R1 about the heat. R1 stated it is a sauna in the facility. Surveyor asked R1 if it changed their appetite or decreased R1's activity participation. R1 indicated that some residents would eat in their rooms if they had air conditioning, but R1 stated they did not notice any change with their activity participation or appetite. Example 4 R3 was admitted to the facility on [DATE] with current diagnoses of congestive heart failure and muscle weakness. MDS (Minimum Data Set) assessment dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 11/15, indicating moderately impaired cognition. On 07/16/26 at 12:19 PM, Surveyor interviewed R3 about the temperature of R3's room. R3 was sitting in the recliner with a fan directed towards R3's face. R3 stated it is stuffy in their room. Temperatures have been extremely hot during the last couple of days and very uncomfortable. Everybody says it is an old building. R3 stated it is extremely hot at night and R3 sleeps in the recliner with the fan on. Surveyor measured the floor temperature which registered at 86.6 F. The wall directly behind R3's recliner measured at 88.2 F. R3 stated staff bring around fresh water and once in a while bring popsicles. R3 stated they are drinking more water now with the heat and they have not been sick or heard of any residents being sick. Example 5 - Hall Temperatures: 100 hall temperatures: On 07/16/26 at 12:14 PM, Surveyor checked the wall temperature in the 100 unit by room [ROOM NUMBER] with a reading of 86.6 F. Surveyor noted in room [ROOM NUMBER] that the wall thermostat needle registered past 88 F mark. Surveyor's infrared thermometer read 87.4 F next to the wall thermostat. On 07/16/26 at 12:36 PM, the wall near room [ROOM NUMBER] measured 87.2 F. On 07/16/26 at 2:27 PM, Surveyor measured the temperature of hallway wall by room [ROOM NUMBER] which read 88.2 F. On 07/16/26 at 2:31 PM, temperature of room [ROOM NUMBER] was 87.8 F. 200 hall temperatures: On 07/16/26 at 2:32 PM, Surveyor observed 2 fans in the 200 hall and Surveyor felt the temperature to be cooler. The wall temperature between rooms [ROOM NUMBERS] read 79.7 F. The wall temperature by room [ROOM NUMBER] was 81.5 F. 300 hall temperatures: On 07/16/26 at 2:36 PM, Surveyor took temperature in the 300/MCU. The main dining area temperature was 84.5. R2 was sitting at the table and was fully clothed. On 07/16/26 at 2:40 PM, Surveyor observed 2 portable AC units in the small TV room. Surveyor observe only 1 AC unit working and a fan in front of the unit blowing air towards the main dining area. The temperature in the tv room was 82.7 F. There were no residents in this area. On 07/16/26 at 2:42 PM, Surveyor observed residents seating in the large TV room on the MCU. The wall temperature was 82.6 F. On 07/16/26 at 2:56 PM, Surveyor with Maintenance C obtained temperatures together in the building. 300-unit dining room wall Maintenance C's temperature read 82 F. Surveyor's temperature read 85 F. Example 6 - Facility temperature observations: On 07/16/26 at 10:49 AM, Surveyor used a calibrated infrared thermometer to obtain the wall temperature of the conference room the temperature read 94.8 F. On 07/16/26 at 12:01 PM, Surveyor entered dining room and noted the curtains were closed, two ceiling fans were working, one floor fan was working, and three portable air conditioning (AC) units were working. Surveyor's temperature readings were 89.6 F on the floor and 89.7 F on the table. On 07/16/26 at 1:10 PM, CNA H (Certified Nursing Assistant) was assisting residents while eating. CNA H informed Surveyor that it was hot in the building recently and she did not think that it affected the amount residents were eating, but it was her first day. On 07/16/26 at 2:27 PM, Surveyor measured temperatures in the dining room during an activity. Temperature on the table registered at 90.0 F. On 07/16/26 at 2:56 PM, Surveyor with Maintenance C obtained temperatures together in the building. The dining room wall: Maintenance C's temperature registered at 87.2 F. Surveyor's temperature registered at 89.2 F. The dining room table: Maintenance C's temperature registered at 88 F Surveyor's temperature registered at 89.6 F. On 07/16/26 at 12:36 PM, Surveyor entered the resident lounge area. The door was closed, and curtains were closed. Portable AC units were working with fans working. The floor temperature registered at 83.4 F, a chair near an AC unit registered at 84.1 F, and wall temperature of 84.8 F. On 07/16/26 at 2:52 PM, Surveyor interviewed NHA A (Nursing Home Administrator) asking if any AC units were purchased for resident rooms. NHA A stated the portable AC units the facility has are placed in the common areas for residents. NHA A stated it would be hard to get AC units for all residents or to pick which residents are to get an AC unit. On 07/16/26 at 12:22 PM, Surveyor interviewed Activities I about activities participation when the building gets hot. Activities I indicated that they still hold activities but change the activity. Today they were going to bake pies, but due to the heat they are not. Activities I did not think the heat caused any less activity participation with the residents. On 07/16/26 at 1:06 PM, Surveyor asked Activities F regarding the heat and if the heat reduced activity participation. Activities F indicated that when it is hot in the building they 'pivot' activities to suit the resident's needs. On 07/16/26 at 2:56 PM, Surveyor interviewed Maintenance C regarding the temperatures in the building. Maintenance C stated the right side of 200 unit is the only part of the HVAC (heating, ventilation, and air conditioning) that is partially working. A couple of years ago a HVAC repair company came to the facility to check the HVAC system and said the HVAC system was not repairable. Surveyor asked Maintenance C regarding the temperatures in R2's room. Maintenance C stated R2's ceiling vent is only blowing circulating air, and the HVAC does not work in the MCU. Maintenance C stated we do not provide AC units for residents. A resident will only have an AC unit if family brings one in. Maintenance C stated the facility has portable AC units for the common areas, but they do not last long they are not built for this type of work. Maintenance C stated they are not aware of the facility purchasing any new portable AC units. Surveyor asked if the portable AC unit in the MCU small TV room is broken. Maintenance C stated the facility likely tripped a breaker when they were installing an AC unit for the resident that resided in the room next to the TV room. Surveyor asked how many residents have AC units in their room. Maintenance C stated only 2 residents. On 07/16/26 at 3:41 PM, NHA A informed Surveyors an HVAC repair company will be coming to the facility tomorrow at 8:00 AM to assess the HVAC system. Surveyor asked if this appointment was just scheduled. NHA A stated NHA A just received notification of the HVAC repair company coming tomorrow.

Based on interview and record review, the facility did not ensure dietary staff had the appropriate competencies and skill sets to carry out the functions of the food and nutrition services. This had the ability to affect all 32 residents.Facility Cook's son, who is not an employee of the facility, was assisting with kitchen duties.The Division of Quality Assurance received concerns indicating [NAME] C was taking pictures in the facility kitchen and posting them on social media on 03/30/26 and photo evidence was provided. The photo contained a caption that read, Thank you Jesus for my son coming to work with me through this dbl . to help his mom out!! . The post showed identified son handling beverages. Surveyor reviewed [NAME] C's social media page and confirmed the photos and captions were still present and open to the public. Surveyor attempted to contact [NAME] C and was unsuccessful.The facility employee handbook Page 5 states in part . all employees will be required to submit a two-stage TB test upon hire. Page 9 states in part . that people are hired on a trial basis for the purpose of assessing abilities to perform assigned tasks and will receive a 6-month orientation period. Page 16 states in part . all visitors should enter the facility at the reception area, receive directions or be escorted to their destinations. Employees are responsible for the conduct and safety of their visitors. Page 19 states in part . all employees will have a personnel file including name, address, phone number, emergency contact, any physical or other limitations, tax and insurance forms, training, education, and undergo reference checks,On 04/28/26 at 9:48 AM, Surveyor visited the facility kitchen and was able to identify where the picture was taken with the whiteboard, door, and refrigerator in the background. At 9:52 AM, Dietary Manager (DM) D entered the kitchen. Surveyor asked if [NAME] C was a current employee. DM D replied, Yes. Surveyor asked if any of Cooks C's children were employed or volunteered in the kitchen. DM D stated they were not; however, the son comes in every so often to visit his mom and it is allowed if wearing a hair net and stays in the back of the kitchen near the exit door. DM D added that visitors are not allowed to touch any food. Surveyor showed DM D the social media picture of a visitor (identified as [NAME] C's son) actively working, handling pitchers of beverages near the counter in the kitchen. DM D verbalized no knowledge of that happening, it is not acceptable, and will educate [NAME] C. On 04/29/26, Surveyor met with Nursing Home Administrator A and two corporate employees to inform them of the above concern. They also reviewed and confirmed the posting on [NAME] C's social media page, appeared very surprised, assured the issue will be addressed, and thanked Surveyor.

Based on interview and record review, the facility did not ensure it had procedures in place to assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals to meet the needs of each resident or contacting the provider when a resident's medication(s) is not available for administration for 1 of 4 residents (R3).R3 was noted to have not received scheduled doses of Xarelto (anticoagulant) and Amiodarone.The facility policy titled Medication/Treatment Administration Error Policy last revised on 04/25, states: Protocol (1)(b): A facility medication/treatment error occurs when a prescribed medication is not available to be administered. Protocol (2)(f) A pharmacy medication error occurs when: a drug is unavailable from the pharmacy that the physician prescribed. Protocol (3) immediately upon discovery of a medication/treatment error, the nurse completes the top section of the Medication/Treatment Error Administration Report and turns it in to the director of nursing or administrator within 24 hours R3 was admitted to facility on 03/18/26 with diagnosis' that included atrial fibrillation, major depressive disorder, asthma, and had a physician order for the following medications: On 04/28/26, Surveyor reviewed R3's admission medication record and noted that R3 did not receive the prescribed significant medication: *Xarelto (anticoagulant) 20mg every evening. R3 had 5 missed doses of scheduled Xarelto. *Amiodarone 200 mg three times a day. R3 had 8 missed doses of scheduled Amiodarone. On 03/19/26 at 6:21 pm, the facility entered a nursing progress notes indicting R3's Xarelto was held due to being unavailable. On 04/28/26, Surveyor reviewed facility incident logs; no identified medication errors were noted on incident log. On 04/28/26, the Surveyor reviewed R3's progress notes. Notes did not reveal there had been any physician notification of medications being unavailable to the facility.On 04/29/26 at 7:36 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding R3 not receiving admission medications for several days and the physician not being contacted regarding the medication not being available. NHA A stated was not aware of R3 not receiving medication and stated the expectation would be that the physician would be contacted for further direction/orders.

Based on interview and record review, the facility did not ensure residents have a right to be treated with respect and dignity, for 1 (R8) of 5 residents reviewed for resident rights.Certified Nursing Assistant (CNA) H searched through and removed items from R8's purse without permission while R8 was out of the room.Findings include:R8 was admitted to the facility on [DATE].On 04/13/26, R8's Minimum Data Set (MDS) assessment showed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating R8 is cognitively intact.R8's diagnoses include aftercare following joint replacement surgery, hypertension, major depressive disorder, chronic pain syndrome, edema, and attention-deficit hyperactivity disorder.On 04/05/26, R8 reported Certified Nursing Assistant (CNA) H went through R8's purse while R8 was receiving a shower from CNA K. R8 reported CNA H removed Tylenol and other medications and had no business being in R8's purse. R8 reported R8's purse was in the nightstand tucked away, and R8 has no idea if CNA H took any other things.On 04/07/26, a progress note from Registered Nurse (RN) N stated: This writer stated we initially found the Oxy (Oxycodone) in R8's purse and that we cannot have residents with narcotics on their person in the building.On 04/28/26 at 8:48 AM, Surveyor attempted to call R8 but R8's phone went straight to voicemail. R8's voicemail box was not setup and Surveyor was unable to leave a message.On 04/29/26 at 10:53 AM, Surveyor interviewed CNA K about the day of the incident. CNA K stated CNA K gave R8 a shower but did not have any information about the events that occurred while doing so.On 04/29/26 at 12:18 PM, Surveyor interviewed RN N about R8's reported incident on 04/05/26. RN N stated R8's oxycodone prescription bottle from home was retrieved from R8 and placed in the medication cart for use. RN N stated RN N believed CNA H had removed it from R8's purse but did not know if CNA H had permission or where the purse was located.On 04/29/26 at 2:28 PM, Surveyor interviewed CNA H about the reported incident. CNA H stated a housekeeper had found a pill on the floor in R8's room and gave it to CNA H. CNA H stated CNA H showed it to a nurse and discovered it was not one that the facility supplied to R8. CNA H stated CNA H was told to go look through R8's room to see where it would have come from. CNA H stated CNA H found the medications in R8's purse which was on the nightstand. CNA H stated CNA H did not have permission to go through R8's belongings.On 04/29/26 at 3:05 PM, Surveyor interviewed Director of Nursing (DON) B about the reported incident on 04/05/26. DON B was unaware of the events and acknowledged CNA H should not have gone through R8's belongings without permission. DON B stated staff should have asked R8 to hand over the medications for safe keeping or send them home with family.

Based on interview and record review, the facility did not ensure it had procedures in place to assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals to meet the needs of each resident or contacting the provider when a resident's medication(s) is not available for administration for 1 of 4 residents (R3).R3 was noted to have not received scheduled doses of ASA (aspirin), Bupropion, Famotidine, Fluticasone salmeterol inhaler, Amitriptyline, and Duloxetine. The facility policy titled Medication/Treatment Administration Error Policy last revised on 04/25, states: Protocol (1)(b): A facility medication/treatment error occurs when a prescribed medication is not available to be administered. Protocol (2)(f) A pharmacy medication error occurs when: a drug is unavailable from the pharmacy that the physician prescribed. Protocol (3) immediately upon discovery of a medication/treatment error, the nurse completes the top section of the Medication/Treatment Error Administration Report and turns it in to the director of nursing or administrator within 24 hours R3 was admitted to facility on 03/18/26 with diagnosis' that included atrial fibrillation, major depressive disorder, asthma, and had a physician order for the following medications: On 04/28/26, Surveyor reviewed R3's admission medication record and noted that R3 did not receive the following prescribed medication: *Aspirin 81 mg one time a day. R3 had 3 missed doses of scheduled Aspirin. *Bupropion HCl ER 300mg one time daily. R3 had 2 missed doses of scheduled Bupropion. *Famotidine 40mg daily. R3 had 3 missed doses of scheduled Famotidine. * Fluticasone salmeterol inhaler twice daily. R3 had 11 missed doses of scheduled Fluticasone salmeterol inhaler. *Amitriptyline 25 mg one time daily. R3 had 3 missed doses of scheduled Amitriptyline. *Duloxetine 60 mg one time daily. R3 had 3 missed doses of scheduled Duloxetine. On 04/28/26, Surveyor reviewed facility incident logs; no identified medication errors noted on incident log. On 04/28/26, the Surveyor reviewed R3's progress notes. Notes did not reveal there had been any physician notification of medications being unavailable to the facility.On 04/29/26 at 7:36 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding R3 not receiving admission medications for several days and the physician not being contacted regarding the medication not being available. NHA A stated was not aware of R3 not receiving medication and stated the expectation would be that the physician would be contacted for further direction/orders.

Based on interview and record review, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (R9) of 3 residents reviewed for accidents.The facility staff did not follow R9's care plan for transfer status. R9 is a Hoyer lift and staff utilize the sit-to-stand mechanical lift for transfers.Findings include:The facility policy titled, Resident Assessment Instrument and Person-Centered Care Planning, last reviewed on 04/2025, states: The Resident Assessment Instrument (RAI).is to be completed by the Interdisciplinary Team (IDT).to identify the strengths, goals, life history and preferences of the resident to develop a person-centered care plan, to provide the appropriate care and services for each resident and to modify the care plan and care/services based on the resident's status.R9 was admitted to the facility on [DATE].On 02/25/26, R9's Minimum Data Set (MDS) assessment showed a Brief Interview for Mental Status (BIMS) score of 3/15 indicating severe cognitive impairment.R9's diagnoses include Alzheimer's dementia, coronary artery disease, hypertension, and peripheral vascular disease.Surveyor reviewed R9's ADL (activities of daily living) care plan, dated 11/11/25, states in part . R9 transfers via Hoyer lift and assist of 2. Toileting requires assistance of 2.Of Note: R9's toileting indicates assistance of 2 but does not indicate what equipment is used for the transfer.On 04/29/26 at 10:08 AM, Surveyor attempted to interview R9 in relation to transfers. R9 was unable to answer questions due to R9's impaired cognition.On 11/18/25 at 11:18 AM, Surveyor interviewed Family Member (FM) M about R9's transfers. FM M stated FM M believed the staff used the sit-to-stand mechanical lift to place R9 on the commode/toilet. FM M was not aware of improper transfers, but stated staff had better be using what is ordered.On 04/29/26 at 12:18 PM, Surveyor interviewed Registered Nurse (RN) N about R9's transfer status. RN N stated R9 was supposed to be a Hoyer lift for all transfers, but that staff did use the sit-to-stand lift for toileting. RN N stated they were talking with Hospice about getting an order to use the sit-to-stand lift just for toileting but had not gotten the official order yet.On 04/29/26 at 2:28 PM, Surveyor interviewed CNA H about R9's transfer status. CNA H stated the Hoyer lift is used for transferring R9 in and out of bed/wheelchair and the sit-to-stand is used for toileting. CNA H stated it's CNA H's understanding this is what was ordered per Hospice.On 04/29/26 at 3:05 PM, Surveyor interviewed Director of Nursing (DON) B about R9's transfer status. DON B stated DON B believed staff used the Hoyer lift for transfers but the sit-to-stand for toileting and this was arranged with Hospice. DON B did state the care plan stated R9 was a Hoyer lift and there was no current order to use the sit-to-stand lift for any transfers.

The facility did not revise 1 (R8) of 12 comprehensive care plans and include person-centered, comprehensive interventions.R8's comprehensive care plan was not updated with person centered interventions.Findings include:R8 was admitted to the facility on [DATE]. On 04/13/26, R8's Minimum Data Set (MDS) assessment showed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating no cognitive impairment. R8's diagnoses include aftercare following joint replacement surgery, hypertension, major depressive disorder, chronic pain syndrome, edema, and attention-deficit hyperactivity disorder.Surveyor reviewed R8's baseline care plan dated 04/02/26 which indicated R8 was a stand and pivot transfer and was continent of bladder.Facility-reported incident report stated that on 04/03/26, R8 reported that Certified Nursing Assistant (CNA) F told R8 to go to the bathroom in R8's incontinent product. R8 told CNA F that R8 would not do that and ultimately CNA F did assist R8 to the bathroom. The report stated that CNA F could not find a bedpan and CNA F was concerned about R8's pain during a transfer as R8 had been recently admitted after a hip replacement. The report indicated R8 was upset by the situation. CNA F was suspended pending investigation. Surveyor reviewed R8's baseline and comprehensive care plans and noted no new interventions were put in place immediately after the reported incident on 04/02/26.On 04/28/26 at 10:04 AM, Surveyor observed no bedpans in the supply closet on the 100 hall medication room, or in either shower room on the memory care unit.On 04/28/26 at 5:38 PM, Surveyor interviewed CNA F about the incident on 04/02/26. CNA F stated the facility did not have a care plan ready and there were no bedpans available. CNA F stated R8 was screaming in pain and CNA F was hesitant to stand R8 because of the pain. CNA F stated that CNA F did not get report on R8 and how R8 transfers. CNA F reported that CNA F told R8 that if R8 was unable to wait for CNA F to find a bedpan or how R8 transfers, then R8 could just go in R8's brief if need be. CNA F reported CNA F was not trying to upset R8 or be mean in any way.On 04/29/26 at 10:20 AM, Surveyor interviewed CNA J regarding following care plans. CNA J stated CNA J would follow the care plan for instructions on how to transfer a resident, and that the care plans are created and available to staff the day of admission.On 04/29/26 at 12:14 PM, Surveyor interviewed Registered Nurse (RN) G about care plans. RN G stated a nurse is assigned to take report from the facility the resident is discharging from prior to admission to this facility. RN G stated the baseline care plan is created and available at the nurse's station upon admission and the CNAs have access to it. RN G stated the nurses also give CNAs verbal report on residents.On 04/29/26 at 2:28 PM, Surveyor interviewed CNA H about transfer status of residents. CNA H stated the transfer status is found on the care plan which is made as soon as a resident is admitted . CNA H stated the bedpans are most often in the main supply closet and reports that some staff assume there aren't any if they aren't found in the small supply closet on the 100 hall. CNA H stated that some staff just don't want to walk down to the main supply closet to get them.On 04/29/26 at 3:05 PM, Surveyor interviewed DON B (Director of Nursing) about information available to staff regarding new admissions. DON B stated the care plan is started right at the time of admission and includes information such as transfer status, diet, bowel and bladder information, and shower information. DON B stated this information would be available to staff on the care plan and CNA care cards. DON B stated the nurse would get report from the other facility and the transfer status of a new admission would be known prior to the resident's arrival to the facility.On 04/29/26 at 3:20 PM, Surveyor interviewed DON B about the education and interventions related to the incident on 04/02/26. Surveyor asked DON B, as part of the interventions for the incident, only 9 nursing staff were educated. DON B stated education was ongoing, and they catch staff as they come in. DON B acknowledged no immediate interventions were placed in R8's care plan and the education was not complete.

Based on interview and record review, the facility did not have evidence that all alleged violations are thoroughly investigated which involved 2 (R6 and R7) of 7 residents reviewed for abuse.The facility did not implement immediate interventions, update care plans, or complete monitoring in relation to a resident-to-resident physical altercation between R6 and R7. Findings include:Facility Policy titled, Resident Safety and Abuse Policy, last revised 02/2022, states Residents have the right to be free from abuse by anyone, including, but not limited to, facility staff, other residents.This system cannot guarantee that abuse will never occur. It can only assure that the facility is doing all that is within its control to prevent occurrences.All alleged violations will be thoroughly investigated.When cause or probable cause is determined, the resident care plan will be revised to ensure a corrective plan is in place to prevent recurrence.R7 was admitted to the facility on [DATE].On 04/28/26, R7's Minimum Data Set (MDS) assessment showed a Brief Interview for Mental Status (BIMS) score of 14/15 indicating R7 is cognitively intact. R7's diagnoses include right femur fracture, type 2 Diabetes Mellitus, muscle weakness, and history of falls.R6 was admitted to the facility on [DATE]. On 03/19/26, R6's Minimum Data Set (MDS) assessment showed a Brief Interview for Mental Status (BIMS) score of 6/15 indicating severe cognitive impairment. R6's diagnoses include atrial fibrillation, Parkinson's disease, major depressive disorder, anxiety, chronic kidney disease, and history of falls.On 04/13/26, the facility submitted a self-report regarding a resident-to-resident altercation between R6 and R7. The report stated that on 04/12/26, R7 was playing cards in the activity room with another resident during a televised church service which R6 thought was disrespectful. R6 went to remove cards and R7 slapped R6's hand away. The report stated R7 and R6 agreed to distance themselves from each other, and R6 agreed R6 should not have attempted to remove the cards. The report stated R6 has no injury and no ill effect. The final report stated R6 stated it was just a misunderstanding and R6 feels safe at the facility.Surveyor reviewed R6's Electronic Health Record (EHR) and noted there was no monitoring in place in relation to the incident on 04/12/26 and regarding R6's statement to Director of Social Services (DSS) E about being scared.Surveyor reviewed care plans for R6 and R7 and noted no updates/interventions were added to R6 and R7's care plans to prevent reoccurrence following the incident on 4/12/26. On 04/29/26 at 11:55 AM, Surveyor interviewed R7 about the incident on 04/12/26. R7 stated R6 can be bossy at times and didn't like that I was playing cards during the church service. R7 stated R6 came over and ruffled up the cards so I cuffed her hand away. Surveyor asked R7 if anyone spoke with R7 after the incident about how to prevent it from happening again. R7 stated that no one had spoken to R7 and that R6 and R7 were getting along fine now. R7 stated R7 has not had any further issues with R6.On 04/29/26 at 12:08 PM, Surveyor interviewed R6 about the incident on 04/12/26. R6 stated the incident is a silly little thing that everyone is making a big deal of. R6 stated it was a little slap that did not leave any marks. Surveyor asked R6 about the statement R6 made to DSS E about being scared. R6 stated that at first R6 was scared because it caught R6 off guard, and then R6 was scared that R6 did something wrong and was afraid R6 would get kicked out of the facility. R6 stated R6 and R7 have had no further concerns.On 04/29/26 at 12:14 PM, Surveyor interviewed Registered Nurse (RN) G about what to do if RN G observes or is informed of physical altercations between residents. RN G stated first RN G would separate the two residents and inform Director of Nursing (DON) B. RN G stated RN G would fill out an incident report and that DON B would guide RN G on what to do next. RN G stated RN G would also maintain the safety of the residents.On 04/29/26 at 3:05 PM, Surveyor interviewed DON B about the follow up and investigation process of the incident on 04/12/26. DON B acknowledged no interventions/updating of care plans to prevent further incidents between R6 and R7.

Based on record review and interview, the facility did not ensure that residents are free of significant medication errors for 1 of 3 residents (R)(R3) reviewed for insulin administration.R3 did not have 2 doses of sliding scale insulin administered per physician order on 02/28/26 and 03/15/26 based on blood sugar result.This is evidenced by:Facility policy titled, Diabetic Blood Sugar Monitoring, with a reviewed date of 11/2022, states in part: Purpose: It is the policy of this facility that blood sugars will be measure and recorded on diabetics per physician orders or when symptomatic. Protocol: 5. If ordered, give sliding scale insulin as ordered by physician.R3 was admitted to the facility on [DATE] with pertinent diagnoses of type 2 diabetes mellitus without complications.R3's physician orders include insulin lispro (short-acting insulin) per sliding scale four times daily of 61-150=0 units; 151-200=2 units; 201-250=4 units; 251-300=6 units; 301-350=8 units; 351-400=10 units; >400=call MD.Surveyor reviewed R3's medication administration record (MAR) and noted:On 02/28/26, R3's AM blood sugar was 154 and 2 units of insulin lispro should have been administered per physician's order. No insulin was administered.On 03/15/26, R3's lunch time blood sugar was 192 and 2 units of insulin lispro should have been administered per physician's order. No insulin was administered.On 03/23/26 at 3:01 PM, Surveyor interviewed Clinical Services Consultant E regarding R3's insulin administration. Clinical Services Consultant E stated that every other weekend, a med tech works with the nurse by taking diabetic blood sugars and informing the nurse of the result to administer insulin. On 02/28/26, a fall had occurred with another resident and the nurse got busy and forgot to give R3's insulin. On 03/15/26, the med tech failed to inform the nurse of R3's blood sugar and the nurse did not administer R3's lunchtime insulin dose. Clinical Services Consultant E stated that this was a medication error and the nurse should have administered insulin on both occasions.

Based on observation, interview and record review, the facility did not ensure the resident's environment remains as free of accident hazards as possible. The facility did not ensure staff followed transfer precautions to prevent accidents for 1 of 2 observations of resident (R)(R3) transfers.R3 was observed transferred by CNA D independently using lift equipment.This is evidenced by:Facility policy titled, Body Mechanics - Transfer Training, with a reviewed date of 11/2024, states in part: Purpose: To provide direction to nursing staff members for training of appropriate body mechanics and safe resident transfer techniques. Protocol: 1. Key Points: b. Reminder that for mechanical sit-to-stand use and mechanical full body lift use, two CNAs, licensed nurse staff or therapists are required to perform the transfer/lift.R3 was admitted to the facility on [DATE] with pertinent diagnosis of dementia.R3's most recent MDS assessment, dated 02/25/26, noted a Brief Interview for Mental Status (BIMS) score of 00, indicating cognition not intact. R3 required substantial/maximal assist with sit to lying and lying to sitting; dependent assist with toileting hygiene, sit to stand, chair/bed transfers, and toilet transfers.R3's care plan, dated 02/09/26, with a target date of 05/16/26, states: [R3] has self-care deficit. Interventions include: Transfer assist: sit to stand lift for all transfers; toileting: assist of 1.On 03/23/26 at 11:16 AM, Surveyor interviewed Certified Nursing Assistant (CNA) G regarding expectations of safe resident transfers using lift equipment. CNA G stated that the expectation is to use 2 staff for all lift equipment transfers.On 03/23/26 at 11:48 AM, Surveyor entered R3's room. Surveyor observed R3's family sitting at table but did not see R3 in the room. At 11:50 AM, Surveyor observed R3's bathroom door open and CNA D was transferring R3 out of bathroom on sit-to-stand lift machine. No other facility staff were present. Surveyor observed CNA D transfer R3 from sit-to-stand lift to wheelchair independently. Surveyor asked CNA D how staff are made aware of a resident's transfer assist needs. CNA D stated on the care plan kept at nursing station. Surveyor asked CNA D if she had received training regarding safe transfer techniques using lift equipment. CNA D stated yes. Surveyor asked what the expectation is for assistance needed to use lift equipment to transfer residents. CNA D stated that 2 staff were to be used.On 03/23/26 at 11:59 PM, CNA D provided Surveyor with R3's care plan and noted that it said R3 required 1 assist for cares and noted the EZ stand was to be used for transfers. CNA D then stated she knew R3 needed 2 staff for using the lift machine but that the nurse was busy at the time and R3 needed to be transferred to the bathroom.On 03/23/26 at 2:45 PM, Surveyor interviewed Registered Nurse (RN) I regarding lift equipment transfers. RN I stated that 2 staff are required for all lift transfers.On 03/23/26 at 2:51 PM, Surveyor interviewed CNA H regarding lift equipment transfers. CNA H stated that as far she was aware, all lift transfers required 2 staff. Surveyor asked CNA H about R3's transfer assist. CNA H showed Surveyor R3's care plan and stated R3 required the sit-to-stand for transfers and that meant 2 staff were needed.On 03/23/26 at 3:01 PM, Surveyor interviewed Clinical Services Consultant E and Regional Director of Operations F regarding observation. Both stated the expectation is for 2 staff to assist with resident transfers using lift equipment. Both agreed that this is a concern as staff are repeatedly educated on the importance of resident safety with lift equipment transfers.

Based on interview and record review, the facility did not ensure that the resident environment remains as free of accident hazards as is possible for 1 or 3 residents (R3) reviewed for transfers.R3 was transferred using a sit-to-stand mechanical lift instead of a full body mechanical lift.This is evidenced by:The facility's policy Body Mechanics-Transfer Training, dated 11/24, includes: To provide direction to nursing staff members for training of appropriate body mechanics and safe resident transfer techniques. ii. If the resident has no ability to sit, stand, or bear weight, DON'T LIFT - use a mechanical assist.R3 admitted to the facility on [DATE]. R3 has a right below the knee amputation.R3's comprehensive care plan includes: 11/12/25 Transfer assist: Full body lift assist of 2.On 12/3/25 at 12:59 PM, Surveyor interviewed CNA H (Certified Nursing Assistant) regarding R3's transfers. CNA H indicated R3 is a full body mechanical lift per R3's care plan. CNA H indicated on 12/2/25 he used a sit-to-stand mechanical lift to transfer R3 instead of the care planned full body mechanical lift. CNA H indicated he should not have done that.On 12/3/25 at 1:06 PM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding CNA H inappropriately transferring R3. NHA A indicated CNA H used a sit-to-stand mechanical lift instead of the full body mechanical lift. NHA A indicated she did educate CNA H regarding following the care plan and transfer training.

Based on interview, and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, that alleged violations are thoroughly investigated for 2 of 3 residents (R1 and R2) reviewed for abuse. A facility staff member reported an allegation of abuse regarding R1 that was not thoroughly investigated. R2's family member reported an allegation of abuse that was not thoroughly investigated. Evidenced by: The facility's policy titled Resident Safety Abuse Policy last reviewed on 3/2024 states in part .8. Reporting Suspected Violations: a. The supervisor on duty shall IMMEDIATELY safeguard the resident(s) and immediately report all alleged violations involving abuse, neglect, mistreatment, exploitation, including injuries of unknown source and misappropriation of resident property to the facility administrator, the Administrator will notify the DON (Director of Nursing) and/or others as appropriate. b. The administrator will report a reasonable suspicion of a crime against any individual who is a resident of or is receiving care from the facility to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located. c. The administrator shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or no later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. 9. Procedure For Investigation: a. All alleged violations will be thoroughly investigated, and all investigations are conducted by or coordinated through facility administration.d. The supervisor will ensure that the resident(s) is/are protected from further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.g. An employee suspected of violation of the Resident Safety Abuse Policy or Social Media Policy may be suspended pending investigation. Example 1 On 11/15/25, NHA A (Nursing Home Administrator) was made aware of an allegation of abuse regarding R1 and CNA G (Certified Nursing Assistant). It is important to note that Surveyor requested the investigation regarding R1. Facility staff provided 3 handwritten interviews that did not include an interview time and/ or signature of interviewee. There were no additional interviews from residents or staff. RN F's interview is as follows: RN F reported to me that there was a situation with R1 and CNA G. Hskpr E says something about CNA G being mean to R1 and that she threw R1's legs in his w/c (wheelchair). His pantleg got stuck in his locks. He can't get it as, so CNA G tried to help but was frustrated because he was doing it all day. Ask RN F to talk with R1. Said they tossed my around- talked cub transfer? Hskpr E's statement is as follows: R1 needed help, so got CNA G. Talked about how his pant was stuck. CNA G yelled? Put his leg harshly on the wheelchair pedal. CNA G's statement is as follows: Wasn't swearing at him, fighting against me and trying to help get his pant leg off the pedal. Asked him to stop moving. Was curt with him and frustrated because he wasn't listening. On 12/3/25 at 2:30 PM, Surveyor interviewed NHA A. Surveyor asked NHA A if they were aware of the allegation of abuse regarding R1 and CNA G, NHA A stated that they received a call about the incident and initiated an investigation. NHA A reported that they received a call from RN F reporting that Hskpr E reported an allegation of abuse, stating that CNA G was yelling and being rough with R1. Surveyor asked NHA A if that is an allegation of abuse, NHA A stated yes. Surveyor asked NHA A if they completed a complete investigation, NHA A stated yes. Surveyor asked NHA A if they interviewed other staff and residents, NHA A stated no. Surveyor asked NHA A if CNA G was suspended or removed from patient care during the investigation, NHA A stated no. Of note: there is no evidence protective measures were put in place to prevent further abuse from occurring. Example 2: R2 admitted to facility on 8/22/25 and has diagnoses that include atrial fibrillation (irregular heartbeat where the upper chambers of the heart quiver due to misfiring electrical signals) and hypertension (high blood pressure). R2's Grievance Report, dated 9/25/25, states, in part: .Describe the situation/issue/complaint: FM D (Family Member) expressed concern of the approach staff had with R2 while transferring her with the EZ stand. She stated they were abrupt with her and had an inappropriate way of communicating with her. Summary statement of resident's grievance: FM D of R2 states staff were using an inappropriate approach when transferring her sister. They made statements such as She was unmotivated, non-compliant, refusing cares and told R2 she could remain in chair. Facility provided interviews with R2, FM D, and 2 cnas (1 that worked with R2 that evening of concern. 1 cna that was not on shift the evening of concern). Surveyor reviewed the facility's education on Approach with Residents, dated 9/25/25, to nursing staff on approach with residents and various situations with different [sic], how to handle situations effectively. There are twenty-four nursing staff signatures. Surveyor reviewed education on Resident Rights/Safety & Abuse Policy, dated 10/09/25, to all staff on understanding approaches with residents and understanding how to go with different situations. Understanding resident rights after background. Resident safety & abuse. There were twenty-nine signatures. On 12/03/25, at 2:00PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked if she was aware of the incident with R2 and staff in September. NHA A indicated yes. Surveyor asked when NHA A became aware of the incident, and NHA A indicated that day, 9/25/25. Surveyor asked if a resident is told they can stay in the chair, go to the bathroom in the chair and sleep in the chair is an allegation of abuse. NHA A indicated yes. Surveyor asked if this incident was reported to the state. NHA A indicated the facility has two hours to investigate the allegation to determine if it was abuse and report to the state in two hours if it was. NHA A indicated she had not reported it to the state. Surveyor referred NHA A to the State of Operations Manual tag F609 and F610. Surveyor asked NHA A what the facility's process is for an allegation of abuse. NHA A indicated to investigate it, interview staff that are involved, complete skin checks, and interview staff. Surveyor asked if the facility completed a full investigation of the incident and NHA A indicated no. The facility did not complete a thorough investigation into allegations of abuse involving R1 and R2. The facility did not put protections in place to prevent further abuse from occurring from the staff involved.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law though established procedures for 2 of 3 residents (R1and R2) reviewed for abuse allegations. A facility staff member reported an allegation of abuse regarding R1 that was not reported to the State Agency or police. R2's family member reported an allegation of abuse that was not reported to the State Agency or police. Evidenced by: The facility's policy titled Resident Safety Abuse Policy last reviewed on 3/2024 states in part .8. Reporting Suspected Violations: a. The supervisor on duty shall IMMEDIATELY safeguard the resident(s) and immediately report all alleged violations involving abuse, neglect, mistreatment, exploitation, including injuries of unknown source and misappropriation of resident property to the facility administrator, the Administrator will notify the DON (Director of Nursing) and/or others as appropriate. b. The administrator will report a reasonable suspicion of a crime against any individual who is a resident of or is receiving care from the facility to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located. c. The administrator shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or no later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. 9. Procedure For Investigation: a. All alleged violations will be thoroughly investigated, and all investigations are conducted by or coordinated through facility administration.d. The supervisor will ensure that the resident(s) is/are protected from further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.g. An employee suspected of violation of the Resident Safety Abuse Policy or Social Media Policy may be suspended pending investigation. Example 1 On 11/15/25, NHA A (Nursing Home Administrator) was made aware of an allegation of abuse regarding R1 and CNA G (Certified Nursing Assistant). It is important to note that Surveyor requested the investigation regarding R1. Facility staff provided 3 handwritten interviews that did not include an interview time and/ or signature of interviewee. There were no additional interviews from residents or staff. On 12/3/25 at 2:30 PM, Surveyor interviewed NHA A. Surveyor asked NHA A if they were aware of the allegation of abuse regarding R1 and CNA G, NHA A stated that they received a call about the incident and initiated an investigation. NHA A reported that they received a call from RN F reporting that Hskpr E reported an allegation of abuse, stating that CNA G was yelling and being rough with R1. Surveyor asked NHA A if that is an allegation of abuse, NHA A stated yes. Surveyor asked if they reported the incident to the State Agency, NHA A stated no. Of note: there is no evidence the allegation was reported to law enforcement. Example 2: R2 admitted to facility on 8/22/25 and has diagnoses that include atrial fibrillation (irregular heartbeat where the upper chambers of the heart quiver due to misfiring electrical signals) and hypertension (high blood pressure). R2's Grievance Report, dated 9/25/25, states, in part: . Describe the situation/issue/complaint: FM D (Family Member) expressed concern of the approach staff had with R2 while transferring her with the EZ stand. She stated they were abrupt with her and had an inappropriate way of communicating with her. Summary statement of resident's grievance: FM D of R2 states staff were using an inappropriate approach when transferring her sister. They made statements such as She was unmotivated, non-compliant, refusing cares and told R2 she could remain in chair. Facility's interview with FM D, dated 9/25/25, no time, states: States staff were using an inappropriate approach with R2. -Non-compliant, refusing cares, unmotivated -States they told her she can stay in her chair, you can fall on the floor -R2 became emotional, tearful, confused -She was hesitant to put her call light on because they won't help me anyway. Facility's Interview with R2, dated 9/25/25, no time, states: They told me to sleep in my chair, so I transferred myself into my bed. They kept saying This is bullshit. This is bullshit. On 12/03/25 at 11:20 AM, Surveyor interviewed FM D. FM D indicated there was on incident that occurred a few weeks after R2 admitted to the facility in September. R2 had to use the bathroom. FM D indicated a cna (certified nursing assistant) was attempting to transfer R2 out of chair with EZ stand. This was new to R2, she had not used an Ez stand prior. CNA was trying to get R2 up and was giving different directions to R2 on how to get up with the EZ stand. The cna was using a very stern voice while speaking to R2 which was causing R2 to become anxious and confused. The cna said to R2 R2 you got to do this! in a strong stern voice. R2 could not understand what to do. FM D indicated the cna was saying R2 was being non-compliant and refusing. FM D indicated that was not the case, R2 was not getting good direction on what to do and was spoken to sternly causing her to become anxious and confused. The cna stated I cannot do this anymore. You can go to the bathroom in the chair and sleep there, and left the room. R2 still had to use the bathroom. FM D indicated another staff member entered the room and said, What is this bullshit going on in here? FM D indicated she did not know the names of the staff members. FM D indicated to Surveyor, FM D thought if the staff talk to the residents like this in front of family, how do they treat residents when family is not around. FM D indicated the next day she took this concern to the social worker. On 12/03/25, at 12:29PM, Surveyor interviewed SW C (Social Worker). Surveyor asked SW C if she recalled an incident that was reported to her by FM D regarding staff interactions with R2 in September. SW C indicated she recalled an incident with R2 being uneasy with the EZ stand; R2 had been a stand pivot transfer and had just changed to an EZ stand transfer. SW C indicated FM D voiced concern that staff's approach was not up to standards when interacting with R2. Surveyor asked SW C what was meant by that. SW C indicated R2 was nervous and uneasy with the EZ stand and staff were not patient with R2 and used a tone of voice with R2 when communicating with her. Surveyor asked SW C if she could explain what is meant by tone of voice. SW C indicated FM D informed her that staff told R2 she could just stay in the chair if she would not transfer out of it. Surveyor asked SW C if there was documentation of this incident, SW C indicated it was filed as a grievance. Surveyor asked SW C what the process is when a concern is brought forward. SW C indicated a grievance form is filled out and investigated. SW C indicated depending on what the outcome of the investigation, the grievance would be given to the administrator and the appropriate action to take would be decided. SW C obtained the grievance and Surveyor and SW C went over it. Surveyor asked SW C what was meant by Inappropriate approach, and being abrupt with R2. SW C indicated staff were being very short and very direct with R2 instead of explaining the process on how to transfer using the EZ stand with R2. Surveyor asked SW C if this incident could be considered an allegation of abuse. SW C indicated staff telling R2 she could stay in chair and not be transferred, yes. Surveyor asked SW C if an allegation of abuse should be reported to the state. SW C indicated any time there is an allegation of abuse it should be reported within 2 hours. SW C expressed FM D just wanted the staff's approach with R2 to be handled. Surveyor asked SW C if she was a mandatory reporter and SW C indicated yes. Surveyor asked if a self-report had been filed, and SW C indicated she did not know. On 12/03/25, at 2:00PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked if she was aware of the incident with R2 and staff in September. NHA A indicated yes. Surveyor asked when NHA A became aware of the incident, and NHA A indicated that day, 9/25/25. Surveyor asked if a resident is told they can stay in the chair, go to the bathroom in the chair and sleep in the chair is an allegation of abuse. NHA A indicated yes. Surveyor asked if this incident was reported to the state. NHA A indicated the facility has two hours to investigate the allegation to determine if it was abuse and report to the state in two hours if it was. NHA A indicated she had not reported it to the state. Of note: there is no evidence the allegation was reported to law enforcement. Allegations of abuse involving R1 and R2 were not reported to the state survey agency within the required time frame and were not reported to law enforcement.

Based on interview and record review, the facility did not ensure that the policy and procedures that prohibit mistreatment, abuse, and neglect of residents were implemented for 2 of 3 residents (R1 and R2) reviewed for abuse. The facility did not implement their abuse policy and procedure as the facility did not report allegations of abuse to the State Agency, did not fully investigate allegations of abuse or put measures in place to protect residents while an investigation was occurring for abuse allegations involving R1 and R2. Evidenced by: The facility's policy titled Resident Safety Abuse Policy last reviewed on 3/2024 states in part .8. Reporting Suspected Violations: a. The supervisor on duty shall IMMEDIATELY safeguard the resident(s) and immediately report all alleged violations involving abuse, neglect, mistreatment, exploitation, including injuries of unknown source and misappropriation of resident property to the facility administrator, the Administrator will notify the DON (Director of Nursing) and/or others as appropriate. b. The administrator will report a reasonable suspicion of a crime against any individual who is a resident of or is receiving care from the facility to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located. c. The administrator shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or no later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. 9. Procedure For Investigation: a. All alleged violations will be thoroughly investigated, and all investigations are conducted by or coordinated through facility administration.d. The supervisor will ensure that the resident(s) is/are protected from further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.g. An employee suspected of violation of the Resident Safety Abuse Policy or Social Media Policy may be suspended pending investigation. Example 1 On 11/15/25, Hskpr E (Housekeeper) reported to RN F (registered Nurse) that CNA G (Certified Nursing Assistant) was yelling/swearing and was rough when assisting R1. On 12/3/25 at 12:30 PM, Surveyor interviewed RN F. Surveyor asked RN F if they were aware of any allegations of abuse regarding R1, RN F stated that a few weeks ago, Hskpr E reported that they had witnessed CNA G cursing and being rough with R1. Surveyor asked RN F if they reported the allegation, RN F stated that it was reported to NHA A (Nursing Home Administrator). Surveyor asked RN F if CNA G was removed from resident care, RN F stated no. On 12/3/25 at 1:30 PM, Surveyor interviewed Hskpr E. Surveyor asked Hskpr E to explain the events regarding R1 and CNA G, Hskpr E reported that they were cleaning R1's room and noted that R1 needed assistance because his pant leg was caught on their wheelchair, and they were not able to move. Hskpr E told CNA G that R1 needed help and that CNA G appeared mad when they entered R1's room. Hskpr E reported that CNA G stated, I told you to stop fucking with shit and proceeded to pick up R1's legs roughly and put them on the wheelchair pedals. CNA G left R1's room, and R1 was still unable to move; R1 then requested to be placed in their recliner. Hskpr E reported that they alerted CNA G, and then left R1's room to go clean another. Hskpr E reported that they could hear CNA G yelling at R1 from down the hall. Surveyor asked Hskpr E if they reported the incident, Hskpr E stated they reported it to RN F. Surveyor asked Hskpr E if they asked CNA G to leave R1's room or remove R1 from the situation, Hskpr E stated no. It is important to note that Surveyor requested the investigation regarding R1. Facility staff provided 3 handwritten interviews that did not include an interview time and/ or signature of interviewee. There were no additional interviews from residents or staff. On 12/3/25 at 2:30 PM, Surveyor interviewed NHA A. Surveyor asked NHA A if they were aware of the allegation of abuse regarding R1 and CNA G, NHA A stated that they received a call about the incident and initiated an investigation. NHA A reported that they received a call from RN F reporting that Hskpr E reported an allegation of abuse, stating that CNA G was yelling and being rough with R1. Surveyor asked NHA A if that is an allegation of abuse, NHA A stated yes. Surveyor asked NHA A if they completed a complete investigation, NHA A stated yes. Surveyor asked if they reported the incident to the State Agency, NHA A stated no. Surveyor asked NHA A if they interviewed other staff and residents, NHA A stated no. Surveyor asked NHA A if CNA G was removed from patient care during the investigation, NHA A stated no. Example 2: R2 admitted to facility on 8/22/25 and has diagnoses that include atrial fibrillation (irregular heartbeat where the upper chambers of the heart quiver due to misfiring electrical signals) and hypertension (high blood pressure). R2's Grievance Report, dated 9/25/25, states, in part: . Describe the situation/issue/complaint: FM D (Family Member) expressed concern of the approach staff had with R2 while transferring her with the EZ stand. She stated they were abrupt with her and had an inappropriate way of communicating with her. Summary statement of resident's grievance: FM D of R2 states staff were using an inappropriate approach when transferring her sister. They made statements such as She was unmotivated, non-compliant, refusing cares and told R2 she could remain in chair. Summary of investigation findings and conclusion: R2 was recently changed to an EZ stand for a transfer status. She was not given proper instruction on how to use the stand and was anxious. Staff are being educated on how to handle these situations more effectively. They were educated on approach with all residents, providing respect, and how to handle various situations with different abilities. Corrective actions taken as a result of the grievance: -Education on approach with various situations with various abilities of residents -Education on how to handle these situations effectively -R2 is a Hoyer lift- she has adjusted well with this transition. Facility provided interviews with R2, FM D, and 2 cnas (1 that worked with R2 that evening of concern. 1cna that was not on shift the evening of concern). Surveyor reviewed the facility's education on Approach with Residents, dated 9/25/25, to nursing staff on approach with residents and various situations with different [sic], how to handle situations effectively. There are twenty-four nursing staff signatures. Surveyor reviewed education on Resident Rights/Safety & Abuse Policy, dated 10/09/25, to all staff on understanding approaches with residents and understanding how to go with different situations. Understanding resident rights after background. Resident safety & abuse. There were twenty-nine signatures. On 12/03/25 at 11:20 AM, Surveyor interviewed FM D. FM D indicated there was one incident that occurred a few weeks after R2 admitted to the facility in September. R2 had to use the bathroom. FM D indicated a cna (certified nursing assistant) was attempting to transfer R2 out of chair with EZ stand. This was new to R2, she had not used an Ez stand prior. CNA was trying to get R2 up and was giving different directions to R2 on how to get up with the EZ stand. The cna was using a very stern voice while speaking to R2 which was causing R2 to become anxious and confused. The cna said to R2 R2 you got to do this! in a strong stern voice. R2 could not understand what to do. FM D indicated the cna was saying R2 was being non-compliant and refusing. FM D indicated that was not the case, R2 was not getting good direction on what to do and was spoken to sternly causing her to become anxious and confused. The cna stated I cannot do this anymore. You can go to the bathroom in the chair and sleep there, and left the room. R2 still had to use the bathroom. FM D indicated another staff member entered the room and said, What is this bullshit going on in here? FM D indicated she did not know the names of the staff members. FM D indicated to Surveyor, FM D thought if the staff talk to the residents like this in front of family, how do they treat residents when family is not around. FM D indicated the next day she took this concern to the social worker. On 12/03/25 at 12:29 PM, Surveyor interviewed SW C (Social Worker). Surveyor asked SW C if she recalled an incident that was reported to her by FM D regarding staff interactions with R2 in September. SW C indicated she recalled an incident with R2 being uneasy with the EZ stand; R2 had been a stand pivot transfer and had just changed to an EZ stand transfer. SW C indicated FM D voiced concern that staff's approach was not up to standards when interacting with R2. Surveyor asked SW C what was meant by that. SW C indicated R2 was nervous and uneasy with the EZ stand and staff were not patient with R2 and used a tone of voice with R2 when communicating with her. Surveyor asked SW C if she could explain what is meant by tone of voice. SW C indicated FM D informed her that staff told R2 she could just stay in the chair if she would not transfer out of it. Surveyor asked SW C if there was documentation of this incident, SW C indicated it was filed as a grievance. Surveyor asked SW C what the process is when a concern is brought forward. SW C indicated a grievance form is filled out and investigated. SW C indicated depending on what the outcome of the investigation, the grievance would be given to the administrator and the appropriate action to take would be decided. SW C obtained the grievance and Surveyor and SW C went over it. Surveyor asked SW C what was meant by Inappropriate approach, and being abrupt with R2. SW C indicated staff were being very short and very direct with R2 instead of explaining the process on how to transfer using the EZ stand with R2. Surveyor asked SW C if this incident could be considered an allegation of abuse. SW C indicated staff telling R2 she could stay in chair and not be transferred, yes. Surveyor asked SW C if an allegation of abuse should be reported to the state. SW C indicated any time there is an allegation of abuse it should be reported within 2 hours. SW C expressed FM D just wanted the staff's approach with R2 to be handled. Surveyor asked SW C if she was a mandatory reporter and SW C indicated yes. Surveyor asked if a self-report had been filed, and SW C indicated she did not know. On 12/03/25, at 2:00PM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked if she was aware of the incident with R2 and staff in September. NHA A indicated yes. Surveyor asked when NHA A became aware of the incident, and NHA A indicated that day, 9/25/25. Surveyor asked if a resident is told they can stay in the chair, go to the bathroom in the chair and sleep in the chair is an allegation of abuse. NHA A indicated yes. Surveyor asked if this incident was reported to the state. NHA A indicated the facility has two hours to investigate the allegation to determine if it was abuse and report to the state in two hours if it was. NHA A indicated she had not reported it to the state. Surveyor referred NHA A to the State of Operations Manual tag F609 and F610. Surveyor asked NHA A what the facility's process is for an allegation of abuse. NHA A indicated to investigate it, interview staff that are involved, complete skin checks, and interview staff. Surveyor asked if the facility completed a full investigation of the incident and NHA A indicated no. The facility did not follow or implement their abuse policy and procedure for two abuse allegations involving R1 and R2.

Based on interview and record review, the facility failed to protect 1 of 3 residents (R1) right to be free from verbal abuse by a Certified Nursing Assistant (CNA).CNA G (Certified Nursing Assistant) was observed to be swearing at and treating R1 roughly when assisting with needs.Evidenced by:The facility policy titled Resident Safety Abuse Policy last reviewed 3/2024 states in part It is the policy of our facility to maintain a work and living environment that is professional and free from threat and/or occurrence of harassment, abuse (verbal, physical, mental or sexual), neglect, corporal punishment, involuntary seclusion, physical or chemical restraints not required to treat the resident's medical symptoms, exploitation and misappropriation of resident property.Providing a safe environment is one of the most basic and essential duties of the facility. Employees have a unique position of trust with vulnerable residents. Having access to private information, being in a physically intrusive position and having elevated status and special relationships with residents, makes ethical and professional behavior essential.Our facility promotes an atmosphere of sharing with residents and staff without fear of retribution.Residents have the right to be free from abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, visitors, friends, or other individuals.The system cannot guarantee that abuse will never occur. It can only assure that the facility is doing all that is within its control to prevent occurrences.Protocol: Federal Definitions: a. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury. b. Verbal Abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/ her family again.R1 was admitted to the facility on [DATE] with diagnoses that include renal cancer, urine retention, and hydronephrosis (where something keeps urine from flowing from the kidneys to the bladder).R1's care plan dated 10/28/25 indicates that R1 requires assistance from 2 staff members for transfers with a full body lift and requires assistance from staff for ADLs (Activities of Daily Living).On 12/3/25 at 10:19 AM, Surveyor interviewed R1. Surveyor asked R1 how things were going for them in the facility, R1 stated My bath is like a party of butchers. What they do to me makes me feel like I'm an animal. Surveyor asked R1 if staff are rough with them, R1 stated that staff do not take their time with them or handle them easy. Surveyor asked R1 if staff swear around them, R1 stated yes. Surveyor asked R1 if they were willing to share the names of the staff members and R1 stated no, and that they were afraid. Surveyor asked R1 if they reported their concerns to anyone, R1 stated that they reported it to the main person that runs the place.On 12/3/25 at 12:30 PM, Surveyor interviewed RN F (Registered Nurse). Surveyor asked RN F if they were aware of any allegations of abuse regarding R1, RN F stated that a few weeks ago, Hskpr E (Housekeeper) reported that they had witnessed CNA G cursing and being rough with R1. Surveyor asked RN F if they reported the allegation, RN F stated that it was reported to NHA A (Nursing Home Administrator). Surveyor asked RN F if CNA G (Certified Nursing Assistant) was removed from resident care, RN F stated no.On 12/3/25 at 1:30 PM, Surveyor interviewed Hskpr E. Surveyor asked Hskpr E to explain the events regarding R1 and CNA G, Hskpr E reported that they were cleaning R1's room and noted that R1 needed assistance because his pant leg was caught on their wheelchair, and they were not able to move. Hskpr E told CNA G that R1 needed help and that CNA G appeared mad when they entered R1's room. Hskpr E reported that CNA G stated, I told you to stop fucking with shit and proceeded to pick up R1's legs roughly and put them on the wheelchair pedals. CNA G left R1's room, and R1 was still unable to move; R1 then requested to be placed in their recliner. Hskpr E reported that they alerted CNA G, and then left R1's room to go clean another. Hskpr E reported that they could hear CNA G yelling at R1 from down the hall. Surveyor asked Hskpr E if they reported the incident, Hskpr E stated they reported it to RN F. Surveyor asked Hskpr E if they asked CNA G to leave R1's room or remove R1 from the situation, Hskpr E stated no.On 12/3/25 at 1:36 PM, Surveyor interviewed CNA G. Surveyor asked CNA G if they had ever been reported for an allegation of abuse, CNA G stated that they have all been reported. Surveyor asked if there were any recent allegations, CNA G stated yes. Surveyor asked CNA G what those allegations were, CNA G stated that someone reported them for being verbally abusive to a resident. Surveyor asked CNA G what happened with the investigation, CNA G stated that they were asked questions about the incident. Surveyor asked CNA G if they were suspended or removed from resident care, CNA G stated no.It is important to note that Surveyor requested the investigation regarding R1. Facility staff provided 3 handwritten interviews that did not include an interview time and/ or signature of interviewee. There were no additional interviews from residents or staff.RN F's interview is as follows: RN F reported to me that there was a situation with R1 and CNA G. (Hskpr E) says [sic] something about (CNA G) being mean to R1 and that she threw R1's legs in his w/c (wheelchair). His pant leg got stuck in his wheelchair lock. He can't get it as [sic], so CNA G tried to help but was frustrated because he was doing it all day. [sic] Ask RN F to talk with R1. Said they tossed my [sic] around- talked cub [sic] transfer?Hskpr E's statement is as follows: R1 needed help, so got CNA G. Talked about how his pant was stuck. CNA G yelled? Put his leg harshly on the wheelchair pedal.CNA G's statement is as follows: Wasn't swearing at him, fighting against me and trying to help get his pant leg off the pedal. Asked him to stop moving. Was curt with him and frustrated because he wasn't listening.On 12/3/25 at 2:30 PM, Surveyor interviewed NHA A. Surveyor asked NHA A if they were aware of the allegation of abuse regarding R1 and CNA G, NHA A stated that they received a call about the incident and initiated an investigation. NHA A reported that they received a call from RN F reporting that Hskpr E reported an allegation of abuse, stating that CNA G was yelling and being rough with R1. Surveyor asked NHA A if that is an allegation of abuse, NHA A stated yes. Surveyor asked NHA A if they completed a complete investigation, NHA A stated yes. Surveyor asked if they reported the incident to the State Agency, NHA A stated no. Surveyor asked NHA A if they interviewed other staff and residents, NHA A stated no. Surveyor asked NHA A if CNA G was suspended or removed from patient care during the investigation, NHA A stated no.

Based on observation, staff interview and record review, the facility did not follow proper food handling practice to prevent foodborne illness. This had the potential to affect all 30 residents residing in the facility.Surveyor observed staff touch ready to eat foods with contaminated gloves.Findings:Facility policy titled, Dietary Department- Personal Hygiene and Cross Contamination Prevention, stated in part: 2. There will be no bare hand food contact with any ready-to-eat foods to help prevent the transfer of viruses, bacteria, or parasites from hands to food. Other pre-approved, alternative procedures for handling and serving ready-to-eat food will be utilized (i.e. use of tongs, serving spoons or forks, use of waxed paper squares, clean glove use, etc.).On 09/16/2025 at 7:39 AM, Surveyor observed [NAME] C wearing single use gloves while cooking. [NAME] C was observed touching multiple potentially contaminated surfaces with gloved hands. Surveyor observed [NAME] C touch the serving tabletop, aluminum foil box, ladle, spatula, microwave, and Robo coupe puree machine. [NAME] C then picked up a sausage link with contaminated gloved hand and stuck thermometer probe into the sausage. [NAME] C then put that sausage link back into the container. [NAME] C then used contaminated gloved hand to pull eggs out of container and put into the Robo coupe.On 09/16/2025 at 1:02 PM, Surveyor interviewed Director of Nursing (DON) B about the observation in the kitchen. Surveyor asked DON B, Was it appropriate to use a contaminated gloved hand to pick up a sausage link to temp it and pull eggs out of a container? DON B replied, No, he should have cleaned his hands and used a new pair of gloves before touching the food and used a utensil; that would have been appropriate.On 09/17/2025 at 10:08 AM, Surveyor interviewed Certified Food Manager (CFM) D about the observation in the kitchen. Surveyor asked CFM D, Was it appropriate to use a contaminated gloved hand to pick up a sausage link to temp it and pull eggs out of a container? CFM replied, No, he should have used tongs to touch the sausage link and a spoon or ladle to pull the eggs out of the container.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility did not ensure that potentially hazardous foods were served at temperatures that would reduce the chance of illness for residents. The facility did not cover food while transporting room trays past resident rooms and in hallways. This has the potential to affect 2 residents (R) (R1, R12) on a pureed diet and 3 of 8 residents (R6, R17, R5) receiving room trays. Findings include: The facility policy entitled, Food Temperatures, dated January 2024, states in part, 4. Take temperatures a. Cooking temperatures must be reached and maintained according to regulations, laws and standardized recipes while cooking . 5. The food service manager will a. review logs daily to ensure that appropriate temperatures are recorded and corrective actions are being taken. b. take corrective action as necessary. The facility policy entitled, Food Temperature Log, dated May 2024, states in part, HOT HOLDING: Typical serving temperature standards . All hot foods should be held at 140 degrees Fahrenheit or above On 07/02/24 at 8:09 AM, Surveyor observed a tray of food delivered to R6. On the tray was a bowl of cereal that had no covering and was exposed. Licensed Practical Nurse (LPN) E delivered the tray walking approximately 100 ft past three other resident rooms with the uncovered food. On 07/02/24 at 8:11 AM, Surveyor observed a tray of food delivered to R17. On the tray was a bowl of cereal, juice, and coffee that had no coverings and was exposed. LPN E delivered the tray walking approximately 50 ft past activity room where residents frequently are and shower room. On 07/02/24 at 8:15 AM, Surveyor observed a tray of food delivered to R5. On the tray was a bowl of oatmeal, juice, and milk that had no covering and was exposed. LPN E delivered the tray walking approximately 80 ft past one other resident room and offices with the uncovered food. On 07/02/24 at 11:50 AM, Surveyor observed food being served for service in the kitchen. During observation Dietary Aide (DA) G was taking temperatures of all foods on the steam table. One item, the pureed lasagna, was checked and the temperature read 128 degrees Fahrenheit. DA G reported that temperature to Dietary Manager (DM) F who recorded the temperature in their logbook and service continued. The pureed lasagna was not reheated and stayed in the steam table. The first pureed diet to be dished was for R12, and when they were making the tray, they did not recheck the temperature and they dished the pureed meal for the resident. The meal was then put into the enclosed metal cart to be delivered. The meal for R12 was then pushed out of the kitchen and was in route for delivery to the resident room. Surveyor asked DM F who would have been served the puree today, and DM F said R12 and R1 were the only two who received the pureed diet that day. These 2 residents had the potential to be affected by the unsafe food temperature. Surveyor then asked DM F and DA G what temperature they would expect food to be held at prior to service. DM F said at least 130 degrees Fahrenheit, they believed. Survey asked what the temperature of the puree had been when they took temperature at the beginning of service, and DA G said it was at 128 degrees Fahrenheit. Surveyor then asked DM F what they would have expected to have been done if any food temperature was found to be below the normal food holding limit. DM F said they should have caught that and heated the puree dishes back up to an appropriate temperature prior to serving. There was no intention of reheating the puree dishes which were to be served to two residents residing in the facility. Before the food could be delivered to R12 it was taken back to the kitchen and reheated. It was noted the signage posted next to the bulletin board in the kitchen read the food should be held at least 135 degrees at the lowest. On 07/03/24 at 8:39 AM, Surveyor interviewed DM F regarding their expectations for the concerns noticed during survey. When asked about covering the food when traveling down the halls, DM F said they would expect food to be covered, and if they were to send an individual tray, they would cover all items on the tray not just the main course. DM F said they would want the food covered if being walked down the hall out of the holding cart. When asked about expectations for holding temperatures for food, DM F said they would expect the food be held at 135 degrees Fahrenheit or above, unfortunately it was missed and won't happen again.

Based on observation, interview and record review, the facility did not ensure a medication error rate of 5% or less. During the medication administration task, Surveyor observed 2 errors out of 27 medication opportunities, resulting in an error rate of 7.41%. This affected 1 of 4 residents (R17) observed for medication administration. R17 received two insulin injections by using injectable pens that a safety check was not completed on to ensure the injectable pens were dispensing insulin before administration. Findings include: Manufacturer's instructions for Basaglar Kwikpen (insulin glargine) state in part.Priming your pen: Priming means removing the air from the Needle and Cartridge that may collect during normal use. It is important to prime your Pen before each injection so that it will work correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat the priming steps, but not more than 4 times. If you still do not see insulin, change the Needle and repeat the priming steps . On 07/02/24 at 8:13 AM, Surveyor observed Registered Nurse (RN) C take two insulin pens out of the medication cart and attach needles to the end of each pen. RN C verified the pens with the orders on the Medication Administration Record (MAR) for R17. One pen was Insulin Glargine 100 units/milliliter (ml) with orders to administer 9 units by subcutaneous (sub-Q) injection daily. The other pen was Insulin Aspart 100 units/ml with orders to administer 3 units sub-Q twice per day. Surveyor observed RN C turn the dose knob to 9 on the Insulin Glargine pen. Surveyor observed RN C turn the dose knob to 3 on the Insulin Aspart pen. RN C did not prime either pen prior to selecting the prescribed dose. RN C carried both pens to R17's room and administered both injections into R17's abdomen per procedure. Immediately following the procedure, Surveyor interviewed RN C and asked if they primed the needles on the insulin pens prior to setting the pens to the prescribed dose. RN C stated they had never been taught that and didn't know they were supposed to do that prior to administering insulin with a pen injector. On 07/02/24 at 8:28 AM, Surveyor interviewed Director of Nursing (DON) B about the policy and procedure for use of insulin pens. DON B was not sure they had a specific policy and procedure for insulin pens and was not sure if insulin pens required priming of the needle prior to administering the dose. DON B stated they follow the manufacturer's instructions for insulin pens. DON B stated they would provide the manufacturer's instructions and facility policy, if they had one, for Surveyor to review. On 07/02/24 at 8:46 AM, DON B provided the manufacturer's information for the insulin pens and stated RN C did not follow the proper procedure for priming the insulin pens prior to administering insulin to R17. DON B stated they would provide education about the proper procedure to RN C and all nursing staff.

Based on interview and record review, the facility did not formulate an advance directive for the resident. Resident (R) 185 did not have orders for the advanced directive they elected for on file, or in a place for emergency personnel to retrieve the information if needed. This had the ability to effect 1 of 13 residents surveyed (R185). Findings include: The facility policy, entitled Cardiopulmonary Resuscitation (CPR) or Do - Not - Resuscitate (DNR) Orders, dated [DATE], states: 1. Upon Admission, the licensed nurse of social worker will discuss the options, CPR or DNR and any other advanced directives with the resident and/or legal representative and received the corresponding physician orders. The Physician Order Summery (POS) is the designated place in the medical record for staff to record/find the CPR/DNR designation for each resident. R185 was admitted on [DATE] to the facility and is able to be understood by peers and understands. On [DATE], record review of R185's hard charts and electronic record could not produce an order for a Cardiopulmonary Resuscitation (CPR) or Do - Not - Resuscitate (DNR). Surveyor could not find a Provider Orders for Scope of Treatment form on file for R185. On [DATE] at 10:26 AM, Surveyor interviewed Registered Nurse (RN) C regarding the process for determining if a person was designated a CPR or DNR. RN C said they would look at the resident's most recent signed orders in the hard charts that were located at the nurse's station. They look at the orders because they are the most up to date source of information regarding the resident's designation for care. On [DATE] at 10:49 AM, Surveyor reviewed the hard charts again and did not find any doctor orders regarding CPR or DNR designations. Surveyor did not find the POST in the hard charts. On [DATE] at 2:19 PM, Surveyor interviewed Quality Consultant (QC) D, regarding the process and missing orders for R185. QC D said the normal process if someone were to need CPR or DNR services would be for staff to look at the hard chart physician orders. If the orders were not signed yet they would have something printed out and on file that looks like the signed orders. QC D and other staff members looked for the orders in the hard charts and in the electronic medical record and could not locate the orders for a DNR. There were orders from the hospital that indicated the resident was a DNR, but these were not accessible to staff who would need them. QC D agreed the orders for the DNR were not accessible, and they would not expect staff to look at the hospital transfer paperwork that was in a different area in the hard charts for a DNR designation. QC D would expect the order sheet be placed in the binder so that staff know where to look in the case of an emergency. QC D, after conversation with Surveyor, contacted the hospital that R185 transferred from and asked for signed orders for the DNR to be placed as soon as possible in the hard charts.

Based on observation, interview and record review, the facility did not assist 1 of 13 sampled and supplemental residents (R19) with eating in a dignified manner by scooping food from her lip and chin with a spoon and feeding it to her. This is evidenced by: Surveyor requested and received the facility policy titled Meal Service Standards which is dated as last revised on 12/18. The policy in part reads: Purpose: The following meal service standards will ensure our residents have a safe, pleasant and enjoyable dining service. Protocol: 1. Dignity: h. All residents are served in a dignified and courteous manner. Surveyor reviewed R19's record and noted the following: The most recent quarterly Minimum Data Set (MDS) completed 12/28/24 notes R19 is dependent on staff to eat. On 3/26/24 at 12:49 PM, Surveyor observed Certified Nursing Assistant (CNA) E sitting at dining room table between R19 and another resident. R19 was faced away from the table in the wheelchair and CNA E was seated at table with her lunch tray. CNA E alternated bites of food that was pureed and drinks of beverages using a glass with a straw. CNA E wiped food from R19's lower lip and upper chin with spoon that she was using to feed resident. CNA E fed R19 the food from her lip and chin. Surveyor observed CNA repeat the swiping food from R19's lower lip and chin with her spoon several times and feeding R19 the food. On 3/27/24 at 8:04 AM, Surveyor observed breakfast in the dining room. CNA E placed R19 at the same table in the same manner as observed for lunch on 3/26/24. CNA E sat at table at R19's side. CNA E was brought R19's breakfast tray of eggs, hot cereal and beverages. CNA E applied a cloth napkin under R19's chin and began feeding her the scrambled eggs and cereal. CNA E alternated feeding R19 and another resident at the table. Surveyor observed CNA E wipe food that was dripping from R19's lip and chin with a spoon and feeding it to her 11 times while assisting her to eat. CNA E did not use the cloth napkin that was placed under R19's chin to wipe the food from R19's lower lip or chin. On 03/27/24 at 2:01 PM, Surveyor spoke with CNA E about the observation. CNA E indicated she works 3 days a week and assists R19 with her meal each day CNA E works. CNA E expressed CNA E has never been told not to use a spoon to wipe food from resident faces and refeed it to them. CNA E further expressed not being aware it is not dignified to do so and frequently clears food from R19's face as Surveyor observed. On 3/27/24 at 3:00 PM, Surveyor spoke with Director of Nursing (DON) B about the observation. DON B explained it is not appropriate for staff to wipe residents' chins or lips with a spoon and re-feed them due to dignity and infection control reasons. DON B indicated staff reeducation will be initiated.

Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 2 of 5 residents reviewed (R28 and R35) of a total sample of 12. R28 has a history of multiple falls. R28 is resistive to assistance and frequently self-transfers despite the risk of fall with major injury. R28 requested assistance to the use the bathroom from a non-direct care staff member on 9/28/22. The staff member noted that R28's pants were lowered when asking for assistance. The staff member did not remain with R28 until assistance was available. R28 fell requiring sutures. R35 fell on [DATE] and an RN assessment was not completed. This is evidenced by: The Facility's Policy entitled Fall Assessment and Prevention Protocol, with a revised date of 8/21, includes, in part: Purpose: A comprehensive, proactive falls assessment will be conducted upon resident admission to the skilled nursing facility and will be reassessed at the time of a resident fall. If/when a resident experiences a fall, a root cause analysis will be conducted to assist in planning appropriate evidence-based interventions to prevent further falls. Protocol: .After a fall or intercepted fall: .See Fall Checklist for licensed nurse to follow. 1. Ensure that the resident needs are met, and the resident is safe. Make them comfortable. Attend to any immediate medical needs and provide appropriate intervention . Ongoing: .2. Any trends or patterns in falls will be evaluated through the facility QAPI (Quality Assurance and Performance Improvement) process on a monthly/quarterly basis. 3. All staff members are regularly educated on resident fall prevention and safety, including proper use and placement of safety devices, use of different kinds of available safety equipment and pertinent manufacturer's directions, and daily surveillance of possible hazards . The Facility Fall Checklist, with a reviewed date of 8/21, includes, in part: 1. Ensure that resident needs are met, and the resident is safe. Make them comfortable. Attend to any immediate medical needs and provide appropriate first aid . R28 was admitted to the facility on [DATE] with diagnoses that include in part: History of Falling; Anemia; Type II Diabetes Mellitus .; Chronic combined systolic (congestive) and diastolic (congestive) heart failure; Restlessness and Agitation; Major Depressive Disorder; Unspecified Dementia (2/3/2021); Neurocognitive disorder with Lewy bodies (2/3/2021) . R28's most recent quarterly Minimum Data Set (MDS) dated [DATE] documents the following: Section C: A BIMS (Brief Interview for Mental Status) of 8, indicating R28 has a moderate cognitive impairment. Section G: .bed mobility 3/2 (extensive assistance/1-person physical assist), transfer 3/2 (extensive assistance/one-person physical assist), locomotion on unit 0/0 (Independent/No setup or physical help from staff), toileting 3/2 (extensive assistance/one-person physical assist) .mobility device: wheelchair. Section J: .Number of falls since prior admission or prior assessment: A. No injury .2 (=Two or more); B. Injury (Except major) 2 (=Two or more); C. Major Injury .0 (=None) . R28's care plan includes, in part: Problem: 7/21/22 Problem: Trauma-Falls, frequent falls with and without injury, risk for major injury/death from fall related to trauma. Approach: 7/25/22 (Discontinued 7/28/22): Nurses - Encourage to ask for assistance, instruct resident in use of adaptive equipment, instruct on safety, remind R28 to toilet before going outside 12/1/20 remind and encourage resident to go slow when completing tasks to prevent injury. Notify provider of increased behaviors causing R28 to become agitated. Offer resident grabber to retrieve items on the floor, frequent checks on room to ensure there are no items on his floor. Offer gentle reminder(s) and cue(s) for toileting after meals and activities. Housekeepers to check resident supplies in bathroom daily and are to leave him with extra supplies. Two trash cans should be in resident's bathroom. Additional furniture, i.e., chair to be placed strategically to allow for clear, clutter free walkway in bedroom. Receives therapy by [Name] in [Name of City]. Provide stable chair of appropriate height for resident when sitting at nurse's station to make his phone calls and a wooden chair while in the dining room per request. Family informed to call staff when returning to facility after out of building trips to request staff assist out of vehicles to prevent falls from vehicles. Grab bar on wall near sink, R28 is known to yell at staff when offering unsolicited assistance, will say to get out of room and that he doesn't want help, continue to encourage R28 to allow at least stand by assist to help prevent major injuries from falls, do leave the room if he is adamant, gripper strips x 2 sets in front of bed exit. 9/22/22 (Discontinued 10/25/22): Nurses -- Encourage to ask for assistance. Call light in reach, Bed height 22 inches marked with tape, ensure tray table within reach while in bed with water pitcher near edge. Gripper strips by toilet bathroom door and bed. Toilet rails with padding, while rounding proactively ensure floor is dry, free from clutter. Laundry hamper by exit of room. Remind him to go slow. Housekeepers to check resident supplies in bathroom daily and are to leave him with extra supplies. Two trash cans should be by the sink in resident's bathroom. Strategically to allow for clear, clutter free walkway in bedroom. Encourage resident to be out of room while housekeeping completes cleaning duties. R28 is no longer able to be in shower room without assist throughout the task. Not to leave him alone. Make sure the shower door is kept locked when not in use. *NOC (Night) shift CNA to offer use of restroom between 5am and 6am. Grab bar on wall near sink. R28 is known to yell at staff when offering unsolicited assistance, will say to get out of room and that he doesn't want help, do leave the room if he is adamant, gripper strips x 2 sets in front of bed exit, gripper strips in place in dining room in from [sic] of his chair, Please have resident use w/c (wheelchair) in room and hallways, needs assist of 1 with all transfers, ADLs (Activities of Daily Living) and toileting, push him to meals and activities in his w/c as needed, please call don't fall signs in bathroom and at bedside, perimeter mattress, mug of thickened liquids at bedside at all times 1/6/23 (Current Approach): Nurses -- Encourage to ask for assistance. Call light in reach, Bed height 22 inches marked with tape, ensure tray table within reach while in bed with water pitcher near edge. Gripper strips by toilet bathroom door and bed. Toilet rails with padding, while rounding proactively ensure floor is dry, free from clutter. Laundry hamper by exit of room. Remind him to go slow. Housekeepers to check resident supplies in bathroom daily and are to leave him with extra supplies. Two trash cans should be by the sink in resident's bathroom. Strategically to allow for clear, clutter free walkway in bedroom. Encourage resident to be out of room while housekeeping completes cleaning duties. R28 is no longer able to be in shower room without assist throughout the task. Not to leave him alone. Make sure the shower door is kept locked when not in use. *NOC (Night) shift CNA to offer use of restroom between 5am and 6am. Grab bar on wall near sink. R28 is known to yell at staff when offering unsolicited assistance, will say to get out of room and that he doesn't want help, do leave the room if he is adamant, gripper strips x 2 sets in front of bed exit, resident use w/c in room and hallways, needs assist of 1 with all transfers, ADLs and toileting, push him to meals and activities in his w/c as needed, please call don't fall signs in bathroom and at bedside, perimeter mattress, mug of thickened liquids at bedside at all times, toileting on NOC at MN, 0200, 0400, 0600 Observe, record, and report all unsafe conditions and situations, Goal: 1/6/23 Free from major injury resulting from falls R28's CNA Assignment Sheet with a Printed date of 1/11/23 includes, in part: Transfer Assist: Assist of 1 at all times. Encourage to ask for assistance, instruct on safety when staff observes him moving quickly . Supportive Devices: dynergo scoot chair. Wheelchair pommel cushion in w/c Grab bar(s) on toilet to assist with standing. Bed has transfer loop, gripper strips in front of bed, toilet and bathroom door, grabber, Hamper at room exit. Safety Equipment: Encourage to use appropriate light in room at night; padding applied to toilet seat arm rails, offer grabber to retrieve items on floor or where reaching is required, while rounding ensure floor is free from clutter i.e., paper towels on floor in bathroom clothes on floor by exit. keep tray table close to side of bed so water pitcher is in reach, perimeter mattress. Toileting: Assist of 1 Attended, wears pull up brief .Offer reminder after meals and activities. Must remain with R28 with toileting at all times, please toilet on NOC (night) shift at MN (Midnight), 2:00AM, 4:00AM, and 6:00AM. Special Care Remarks: .anticipate needs Remind to wear prescription glasses. (Refuses eye glass use) Housekeepers check his supplies daily and leave with extra .Keep room clear and clutter free, inc. furniture. Ensure floor is dry and free of obstacles after he finishes his meals. Keep appropriate footwear at bedside. Encourage to activities outside of room while room is being cleaned. Gripper strips in front of sink, in front of the toilet, and at bedside, please call don't fall sign in bathroom and resident room. Use printed daily agenda for R28's routine, assist with bedtime routine at 7pm, call don't fall sign in room and bathroom. Of note, on 1/12/23 at 2:35 PM, Surveyor observed the agenda on R28's wall to contain, in part: 10AM bathroom; 11:30 Bathroom and to activities; 12:45 pm bathroom; 2:00 pm bathroom; 4:00 pm bathroom; 7:00 - 7:30 pm bathroom cares and to bed. These interventions were not clearly defined in R28's plan of care; a staff member would need to go to the bathroom and read the printed agenda to have knowledge of R28's routine. On 1/10/23 at 1:02 PM, Surveyor interviewed R28 as part of the initial screening process. Surveyor asked R28 if he recalled having any falls in the last few months. R28 stated he had a fall out of his chair, and something happened to his head, and he went to the hospital. R28 was not able to give a date or any more detail regarding the fall. Review of July 2022 through September 2022 fall incident reports and Nursing notes provided to Surveyor for R28, include in part, the following: Risk and Benefit documentation, dated 6/29/22 at 10:08AM, related to R28's falls, was provided to the Surveyor by the facility and includes the following: Spoke with family/guardian, FM L (Family Member) and [Name]. Regarding: recent falls and R28's continued refusals to let staff assist with ambulation and ADLs .Risk and benefit discussion as to allowing R28 to assert his right to maintain his independence despite risk to his personal safety including major injury and death resulting from falls is discussed. FM L and [Name] agree that R28 has a right to choose although they wish he would allow staff to help, they are aware of his right and choice to refuse assistance despite many education sessions discussing with R28 the risks of his choice to be independent when he clearly is not safe and will continue to have falls . On 1/12/23 at 3:39 PM, Surveyor spoke with FM L (Family Member) and asked if she recalled a conversation regarding risk and benefits in relation to R28's falls and him having the right to choose to be independent despite the risk of major injury. FM L indicated she did not recall this conversation with the facility and that the facility needs to be helping him transfer from that chair especially when you can't put the brakes on. Surveyor clarified with FM L that she did not recall a discussion of risks and benefits of R28 self-transferring and that despite the education and attempts at interventions he still self-transfers. FM L indicated, no, I don't. Surveyor asked FM L if she recalled agreeing that R28 has the right to maintain his independence and choose to self-transfer. FM L indicated, no, he doesn't, they need to help him transfer. July 2022: 7/3/22 1:57 AM Incident Report, includes, in part: Incident Type: Lowered to Floor Injury: No apparent injury Location: Bathroom Activity at the time: Walking to the bathroom unassisted with walker in the dark, yelled at staff when lights were turned on, right leg dragging behind and unable to stay safely standing, gently lowered to the floor, and assisted back up. Assessment Supporting Intervention: Resident care planned for injury prevention as he is anticipated to fall r/t (related to) his desire to remain independently. [sic] 7/6/22 9:23AM Nurses notes: Follow-up of Incident: Lowered to floor 7/3/2022 1:57AM, Injury: No apparent injury. Actions: .IDT team review. R28 continues to transfer, ambulate, and perform ADLs independently despite being unsafe to do so, staff continue to monitor and intervene as resident will allow. 7/9/22 5:45AM Incident Report, includes, in part: Incident Type: Observed on Floor Injury: No apparent injury Location: Resident's room Activity at the time: Walking Assessment Supporting Intervention: Resident refused to ask for assistance and falls frequently. Care Planned for frequent falls. A handwritten note in this section indicates, Grab bar on wall near sink. 7/10/22 6:05AM Incident Report, includes, in part: Incident Type: Observed on Floor Injury: No apparent injury Location: Bathroom Activity at the time: Toileting; hygiene care via the sink in his bathroom Assessment Supporting Intervention: Bathroom sink filled with water, resident verbalized that he was washing himself with the water he collected in the sink and slipped on the water that spilled on the floor. A handwritten note in this section indicates: Grab bar on wall near sink. 7/12/22 1:30AM Incident Report, includes, in part: Incident Type: Observed on Floor Injury: Skin tear left forearm reopened Abrasion between nose Location: left forearm, lip, between upper lip and nose Location: Resident's room Bathroom Activity at the time: Toileting Assessment Supporting Intervention: resident refuses to use his call light for assistance, staff has heard the walker and went to assist him, and he tells us to get out and mind our business and that he does not need our help. A handwritten note in this section indicates: Set-up conference; Review Mayo notes; -Neuro; Rehab director contact [Name] therapy 7/12/22 6:00 AM Incident Report, includes, in part: Incident Type: Observed on Floor Injury: No apparent injury Location: Resident's Room Activity at the time: Transferring/Walking Assessment Supporting Intervention: IDT (Interdisciplinary team) to review 7/12/22 6:09AM Nurses Notes: Follow-up of Incident: Resident found on floor in bathroom. Had a cutt [sic] on his left forearm, lip was cutt [sic], and between his mouth and nose is an abrasion. He refused vitals and said he didn't hit his head. MD and DON (Director of Nursing) were updated, POA (Power of Attorney) still needs to be updated. 7/12/22 12:54PM Nurses Notes: Follow-up of Incident: Observed on floor 7/12/22 @ 1:30AM and 6:30AM. Injury: Skin tear: Abrasion: Actions: .IDT team review: Comprehensive discussion held on 7/12/22, plan: conference to be set up with medical Director, [Name of outside Therapy] Therapy Team, Dr [Name] Facility IDT, resident and POA to discuss resident's multiple falls and comprehensive plan of action, [Name of outside Therapy] notes for last 6 months reviewed and yield little information not already known, Director of Rehab services to contact [Name of outside Therapy] Therapy to discuss case, also will discuss with resident the use of w/c locomotion. Further interventions based on outcome of above. 7/20/22 1:00PM Incident Report, includes, in part: Incident Type: Witnessed fall Injury: Laceration right upper arm, next to elbow 0.2cm x 0.5cm First Aid: cleansed with wound cleaner, covered with xeroform and gauge [sic] dressing immediately applied Location: Dining room Activity at the time: Transferring/Walking Assessment Supporting Intervention: IDT to review 7/21/22 2:25PM Nurses Notes: Follow-up of Incident: Witnessed fall 7/20/22, observed to stand up in dining room when his foot caught on the chair which caused him to slide to the floor Injury: Laceration: small laceration right upper arm Actions: .IDT team review: R28 continues to assert self-determination and ambulate and complete ADLs independently despite not being safe to do so. R28 does not allow staff to assist even when he is observed being unsafe and staff attempt to intervene .Care plan is current with care plan for falls but to avoid major injury which at this time likely will be unavoidable due to his level of resistance and self determination to continue to be independent. POA has been contacted on several occasions to schedule specialized care conference to discuss concerns with R28 but has declined to give any available times for this to occur . 7/22/22 6:00AM Incident Report, includes, in part: Incident Type: Observed on Floor Injury: No apparent Injury Location: Resident's room Activity at the time: Transferring Assessment Supporting Intervention: ongoing review of care plan. A handwritten note in this section includes 2nd set of gripper strips in front of bed, update care plan with care refusal. 7/25/22 1:09PM Nurses Notes: Follow-up of Incident: Observed on floor 7/22/22, resident was sitting up on edge of bed, unassisted as per his usual choice, lifted his leg to take off his pajama pants and slipped off the edge of the bed to the floor. Resident has grab bar in place as well as one set of gripper strips in front of bed. Injury: No apparent injury. Actions: .IDT Team review: Room assessment shows gripper strips in place on floor in front of bed, these possibly do not cover the entire surface area of where his feet potentially could end up when attempting to self-transfer or perform ADLs independently. Will have maintenance place a second set of strips adjacent to current set. Also care plan updated to reflect his continued refusals for help even when staff comes in to attempt to intervene and assist when noted to be unsafe, he will yell and say to get out of here, I'm fine, I don't want help 7/26/22 4:00PM Incident Report, includes, in part: Incident Type: Observed on Floor Injury: Skin tear Laceration Resident verbalized that he bit (documentation ends here) . Location: left arm Measurement: 1 cm x 0.5cm First Aid: Immediately applied Location: Bathroom Activity at the time: Toileting Assessment Supporting Intervention: Resident verbalized that he fell over his walker 7/28/22 11:55AM Nurses Notes: Follow-up of Incident: Observed on floor 7/26/22, observed on the floor in his BR (bathroom), stated his walker fell over causing him to fall. Injury: Laceration left upper lip, states he bit it while falling, however blood was noted on the toilet bowl leading to the conclusion he may have struck his face on the toilet, Skin tear: left forearm. Actions: .IDT team review met with case worker from [Name] 7/27/22, discussed R28 at length and challenges with R28's self-determination leading to his numerous falls and the risk that places him at for major injuries .Also discussed his POA and unwillingness to meet with our IDT team to further discuss care plan and challenges. Case worker will be reaching out to the POA as well as asking his supervisory team to review R28's case and offer any suggestions for fall management .Monitoring with R28 will be ongoing and falls are anticipated and unavoidable related to his self determination to continue to remain independent, goal continues to remain at prevention of injury. 7/27/22 1:45PM Incident Report, includes, in part: Incident Type: Witnessed fall Injury: No apparent injury Location: Dining room Activity at the time: Transferring Assessment Supporting Intervention: IDT to review 7/28/22 12:51PM Nurses Notes: Follow-up of Incident: Witnessed fall 7/27/22 in the dining room while getting up from his chair. Injury: Other (Specify): did strike the back of his head on the shelf of a metal cart that was nearby [sic], resident was adamant that he did not hit his head, even though this was witnessed and did not want his POA contacted or told he had struck his head. Actions: .IDT team review: R28 continues to have multiple falls, will place gripper strips in DR (dining room) in front of his chair he always sits in and will place chair up against the wall to help prevent the chair from tipping when he is getting up as he does not allow assist with this. 7/30/22 8:10PM Incident Report, includes, in part: Incident Type: Observed on floor by staff but witnessed by Injury: No apparent injury. Location: complains of neck hurting Location: Activity room Activity at the time: Transferring from chair to standing First Aid: Neuro checks WNL (within normal limits) no apparent injury but does state it hurts to turn his head. Transferred to emergency room Assessment Supporting Intervention: send to ER 7/31/22 5:25PM Incident Report, includes, in part: Incident Type: Witnessed Fall Injury: No apparent injury Location: Hallway Activity at the time: Walking Assessment Supporting Intervention: Per staff resident sped out his room after being assisted, took a sharp turn in his doorway, and stumbled to the floor. 8/1/22 11:43AM Nurses Notes: Follow-up of Incident: Observed on floor 7/30/22 @ 8:10PM Witnessed fall 7/31/22 at 5:25 PM. Injury: c/o neck pain and right knee pain. IDT team review: Numerous interventions are in place for R28, continues to ambulate unsafely without assist. Most recent falls are 7/30 and 7/31 after which he was c/o neck pain and knee pain. Seen in ED 7/30/22 and discharged in the AM on 7/31/22. Multiple scans performed in the ED, including CT head/c-spine, which were negative but limited d/t motion artifact as R28 was being uncooperative .R28 told the ED MD he feels he may have blacked out, [sic] EKG (Electrocardiogram) performed NSR (Normal Sinus Rhythm) with right BBB (Bundle Branch Block), recommendation is to have [NAME] monitor placed at [Name] Clinic on outpatient basis to r/o (rule out) cardiac causes. Staff will continue to attempt to intervene and assist as R28 will allow and outpatient visit at [Name] clinic for f/u (follow-up) is pending. August 2022: 8/1/22 2:25PM Incident Report, includes, in part: Incident Type: Witnessed Fall. Injury: No apparent injury Location: Hallway Activity at the time: Walking Assessment Supporting Intervention: Resident was leaving shower room, he attempted to close the door, the shoe on his right foot came off he tried to put his foot back in it, but he started stumbling and fell backward. 8/1/22 4:39PM Incident Report, includes, in part: Incident Type: Observed on Floor Injury: Laceration bridge of nose and linear in his hair line. Location: face and head. Measurement: R28 refused any assessment Location: Resident's Room Activity at the time: Transferring trying to pick up a clock that he had dropped First Aid: pressure dressing to nose and head immediately applied. Transferred to emergency room . 8/2/22 3:55PM Nurses Notes: Follow-up of Incident: Observed on floor 8/1/22 @ 4:39PM Witnessed fall 8/1/22 @ 2:25PM falls x 2 this date. resident continues to be unsafe to ambulate, sent to ED via ambulance after 2nd fall this date with possible head injury. New scans were obtained and do show a C5 spinous process fracture which is new compared to previous studies from 7/2022, non-concerning per ED MD assessment. Multiple recent falls, including a fall this AM 8/2/2022 .R28 was unable to stand unassisted at that time, he was placed in a w/c and extensive education given regarding w/c safety and the need for R28 to call for assist with all transfers and ADLs (Activities of Daily Living), very reluctant but did concede to this. So far this date he has been compliant with w/c use. After multiple attempts by floor RN staff the POA was updated on his condition and appears to be in agreement with change of care plan . An emergency room note for R28, dated 8/1/22, indicates, in part, the following: Chief Complaint: States trip and fall and has hematoma to head and abrasion to the nose. History of Present Illness: R28 .presenting via ambulance following a repeat fall .On 7/30/22 he had a witnessed fall in the common area of the nursing home at approximately 2005 (8:05PM). After the fall he was able to get up and use his walker and go back to his room. Nursing home has called the ambulance this evening because patient had an unwitnessed fall. He struck his head; he has a nasal abrasion .Patient has told us about a cervical spine fracture in the past and this is included on his [Name] Clinic documentation/problem list . Physical Exam: .He has a large area of contusion on the mid cranial scalp region .Neck: Supple, non-tender. There is no palpable step-off .Skin: Large area of contusion at this cranial scalp and an abrasion to his nose . Assessment/Plan: 1. Fracture of cervical spinous process .Patient has a new C5 spinous process fracture compared to studies from late July 2022 also done at this facility. Dr. [Name], radiologist, has reviewed images from late July and from today. He this [sic] is a stable fracture because he has previous cervical spine fusion. Neurosurgeon, Dr. [name] .has reviewed patient history and at this time indicates that pain control only is indicated at this time. No collar is indicated. Because of patient's previous history of spinal fusion patient should have imaging of his neck if he has a fall that is unwitnessed . Impression CT Cervical: 1. C5 spinous process fracture extending into the inferior articular facets. 2. Otherwise, no acute displaced osseous injury or traumatic malalignment . 8/2/22 8:15AM Incident Report, includes, in part: Incident Type: Observed on Floor Injury: No apparent injury Location: Bathroom Activity at the time: Walking Assessment Supporting Intervention: R28 is unsteady on his feet and his walker is not sufficient to aid his steadiness. IDT to review. 8/2/22 9:30PM Incident Report, includes, in part: Incident Type: Observed on Floor Injury: No apparent injury Location: Resident's room Activity at the time: Transferring Assessment Supporting Intervention: Resident did not use his call light for assistance, resident attempted self-transferred [sic] from bed to wheelchair. 8/3/22 4:00AM Incident Report, includes, in part: Incident Type: Observed on Floor Injury: No apparent injury Location: Resident's room Activity at the time: Walking Assessment Supporting Intervention: resident walked around w/c which was at bedside and fell behind it when attempting to walk to the bathroom. Non-skid strips by toilet. 8/3/22 7:45AM Incident Report, includes, in part: Incident Type: Witnessed fall - did not hit head Injury: Laceration. Location: dorsal side of left hand. Measurement: 1.25cm long. Location: Resident's room Activity at the time: Transferring First Aid: Immediately applied Assessment Supporting Intervention: IDT to review 8/4/22 3:16PM Nurses Notes: Follow-up of Incident: Observed on floor 8/2/22 @ 8:15am, observed on floor 8/3/22 @ 4:00AM, and Witnessed fall 8/3/22 @ 7:45AM. Actions: .IDT team review: R28 has agreed to w/c us [sic] and requesting staff assist as he is too weak and unstable to provide cares for himself, he is weak and unsteady to the point he cannot [sic] sit up at bedside unassisted and this is believed to be the cause of his falls on 8/3/22, extensive education to R28 by this writer on 8/3/22 that he must remain in the laying position in bed and wait until staff arrive to the room to assist him up and out of bed .He states understanding and has been compliant over the last 36 hours. Care Conference with Managed Care team, POA and IDT scheduled for 8/8/22 . 8/4/22 8:17PM Incident Report, includes, in part: Incident Type: Observed on floor Injury: Skin tear. Location: Right elbow. Measurement: 1cm x 1 cm Location: Resident's room Activity at the time: Transferring First Aid: Immediately applied Assessment Supporting Intervention: Resident verbalized that he slipped out of his wheelchair. 8/6/22 7:00PM Incident Report, includes, in part: Incident Type: Observed on floor Injury: No apparent injury Location: Bathroom Activity at the time: Transferring Assessment Supporting Intervention: Resident resistive to recommended treatment and care. 8/9/22 7:40AM Incident Report, includes, in part: Incident Type: Witnessed Fall Injury: Skin tear. Location: Left Forearm. Measurement: 1.2cm x 1cm. Location: Resident's room Activity at the time: Transferring First Aid: Immediately applied skin flap in place, wound cleansed, xeroform placed and covered with 4x4 gauze, wrapped with kerlix. Assessment Supporting Intervention: IDT to review 8/9/22 6:00PM Incident Report, includes, in part: Incident Type: Observed on Floor Injury: Laceration. Location: right forehead. Measurement: 1 cm x 1 cm x .2cm. Location: Bathroom Activity at the time: washing his hands in the sink First Aid: Immediately applied Assessment Supporting Intervention: Resident has his of nonuse [sic] of his push button call light. 8/10/22 12:15PM Nurses Notes include, in part: Spoke with R28 at great length this am about concerns for his floors in his room are slippery and difficult to dry when wet both in his bathroom and room. Did show him an alternative room with floors not as slippery and closer to writer's office to allow more access for assist and he was stern about staying where he is. Did discuss risk vs benefits but he states he is not moving. Also reviewed his daily routine in detail to present a visual itinerary for both the staff and resident to review and plan when he is of need for assistance closer. Will print this up on bright colored paper to alert for reminders. R28 states he does not intend to call for help all the time as he can do it himself and is in denial of needing help .Reviewed the care plan with him and he states he does not need all of that on there for assist with cares and became assertive. Discussed bathroom floor being extra slippery when he uses the soap dispenser, and it falls to the floor, and he washes up getting floor very wet with standing water and soap. To try to provide him a hand pump soap dispenser that he may be able to manage better. Incident Report, includes, in part: 8/11/22 6:45PM: Incident Type: Witnessed Fall Injury: Skin tear. Location: left arm posterior. Measurement: 1cm x 1cm. Location: Activity room Activity at the time: I was trying to move the chair First Aid: Immediately applied Assessment Supporting Intervention: Resident verbalized that he was moving a chair that was in his way. 8/19/22 3:41PM late entry for 8/18/22 Nurses notes: Follow-up of Incident: Witnessed fall, 8/17/22, fell backwards into the toilet tank. Injury: Abrasion: mid lumbar region. Actions: .IDT team review: . [Initials] was with resident in bathroom, stated she left bathroom to retrieve linen items, on her return she observed R28 to be standing up from the toilet without assist in her absence, witnessed him to fall backwards striking his back on the toilet tank. RN had requested maintenance to pad toilet tank, this request was cancelled by this writer as this is unsanitary and will not prevent falls, root cause is him being left unattended in the bathroom, care plan update [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 3 of 3 residents (R1, R2, and R3) reviewed for supervision and resident to resident altercation. R1 has a known history of inappropriately touching other residents. The facility implemented an intervention of line of sight supervision. That supervision was not consistently provided allowing R1 the opportunity to again seek out residents and inappropriately touch them on multiple dates. After 3 incidents, all of which occurred while R1 was supposed to be under line of sight supervision, the facility implemented 1 to 1 supervision. Observations found staff would not keep R1 within their line of sight and would not ensure R1 was within arms reach. During one of these observations, R1 was able to seek out a resident he had a previous incident with. The facility's failure to provide adequate supervision for R1, with known physical and sexual contact with other residents, created a finding of Immediate Jeopardy (IJ) that began on [DATE]. On [DATE] at 4:41 PM NHA A (Nursing Home Administer), and ANHA C (Assistant Nursing Home Administrator) were notified of the IJ concern. The immediate jeopardy was not removed at the conclusion of the survey. This is evidenced by: The facility's Elopement and Wandering Management Policy updated ,d+[DATE] includes in part: It is the policy of this facility to make every reasonable effort to provide for the safety and security of residents at risk for elopement . Resident wandering behaviors must be assessed and monitored in order to protect the safety and welfare of residents . 2. For each resident identified as having wander behavior . an appropriate safety care plan . will be developed and implemented with specific approaches, preventative measures and measurable goals . Of note this policy addresses staff intervention for resident elopement and elopement attempts but does not specifically address how staff should respond to residents wandering into other residents rooms. R1 was admitted to the facility on [DATE] with diagnoses including: mild cognitive impairment of uncertain etiology, age related cognitive behaviors, and bilateral hearing loss. On [DATE], a diagnosis of Alzheimer's dementia was added to R1's record by R1's physician. On [DATE], R1 was diagnosed with dementia with associated psychotic-agitated behavior. R1 has an APOAHC (Activated Power of Attorney for Health Care). On [DATE], R1's admission MDS (Minimum Data Set) assessment notes a BIMS (Brief Interview for Mental Status) score of 2, indicating severe cognitive impairment. Section E of the MDS notes R1 wandering behaviors occurred daily. Section G notes R1 is independent in transfers, ambulation, and locomotion on the unit. R1's Care Plan notes: ~Problem: need for appropriate sexual expression/display of affection (dated [DATE]), Related to touching peers and staff in affectionate manner with or without sexual intent, ex (example), cues to have hand held, habit of placing his hand on others back, placing hand on shoulders of others, close talking near peers faces due to impaired hearing, low BIMS (dated [DATE]). ~Approach (dated [DATE]): Nurses-One to one, redirect immediately, be mindful of personal space and uninvited entrances into others space . Monitor personal boundaries and document redirecting needed and any inappropriate behaviors, document interventions, involve family . provide ample 1:1 and/or independent activities with meaningful tasks (see activity care plan), social distance from opposite sex (i.e. provide appropriate boundaries between opposite sex). Monitor/intervene immediately prior to socially inappropriate touching and close talking to others, remind of personal boundaries. If defiant/aggressive behavior occurs, try reality orientation, involve family, validate concerns and emotions and remind of appropriate behaviors/actions. R1's Care Plan included an approach dated [DATE] to Keep resident in line of sight when up, this approach was discontinued on [DATE] when 1 to 1 was implemented. Review of R1 record notes R1 has specific behaviors which are monitored each shift as follows: -On [DATE], the facility monitored R1 for exit seeking (R1 is a known wanderer and is independent in ambulation), with these behaviors documented as occurring ,d+[DATE] times per day [DATE]-[DATE]. -On [DATE], the facility added monitoring R1 for behaviors of socially inappropriate touching of peers. Documentation shows these behaviors occurred ,d+[DATE] times per day between [DATE]-[DATE]. -On [DATE], the facility added monitoring R1 for behaviors of socially inappropriate touching or sexual comments to staff. Documentation shows these behaviors occurred ,d+[DATE] times per day between [DATE]-[DATE]. -On [DATE], the facility added monitoring R1 for targeted behavior of Persistent anger: pushing, slapping or other aggressive behavior toward staff. Socially inappropriate/disruptive shoving furniture, kicking doors. Documentation shows these behaviors occurring ,d+[DATE] times per day from [DATE]-[DATE]. R1's Nurses Notes include in part: -On [DATE], at 9:13 AM, . Resident moved to MCU (Memory Care Unit) [DATE] Resident in adjustment period. Wanders around MCU thinks one of the other residents is his deceased wife. Supervision needed at all times due to inappropriate touching of other residents. Have revised CP (Care Plan) addressing this and updated activity preferences. -On [DATE], at 9:13 AM, . Resident moved to MCU (Memory Care Unit) [DATE] Resident in adjustment period. Wanders around MCU thinks one of the other residents is his deceased wife. Supervision needed at all times due to inappropriate touching of other residents. Have revised CP (Care Plan) addressing this and updated activity preferences. -On [DATE], the facility notified R1's physician of R1 restlessness and difficulty sleeping, Melatonin was ordered. POA (Power of Attorney) was in agreement. -On [DATE] at 2:00 AM, Behavior: pushing/ Grabbing Pinching behavior occurred ,d+[DATE] days in the last 7 days. Verbal Threatening Cursing at Others' Behaviors occurred ,d+[DATE] days in the last 7 days . Impact of Resident: this note indicates the R1's behaviors puts R1 at significant risk for physical illness or injury, and puts others at significant risk for physical injury, significantly intrudes on the privacy or activity of others . Intervention: 1:1, assessed for pain . left alone and reapproached, music, offered snack, phone call to family, redirected . Behavior change: Behavior status has deteriorated since the last assessment. -On [DATE] at 4:02 PM, the facility sent a fax to R1's physician requesting a medication change related to anxious behaviors, agitation/aggression. -On [DATE], 3:20 AM, R1 was presenting with behaviors, staff were providing one to one for R1 at the time, the facility called 911 and R1 was sent emergently to the hospital for evaluation of agitated behaviors including swearing, yelling, attempting to enter other resident's rooms carrying and moving furniture. The facility received new orders to increase Seroquel to 50 MG every 12 hours. POA in agreement. On [DATE] at 10:50 AM, Surveyor interviewed CNA J (Certified Nursing Assistant) about R1's behaviors and what interventions are in place to protect other residents from R1. CNA J explained R1 was placed one to one supervision about a week ago, and that staff were assigned specific times to be within arm's reach of R1 and keep him from contact with other residents. CNA J stated there was a log sheet to document the one on ones. Surveyor asked what was in place before the one on ones were started, CNA J stated the staff kept R1 in direct line of sight and would redirect R1 if R1 came close to other residents. 39849 Example 1 The facility self-reported an incident related to R1 and R3 that occurred on [DATE]. The report indicated, R1 reached out toward R3 and touched them in the arm and inadvertently touched the side of their breast with the back of their hand. R1 has a tendency toward physical contact which may include rubbing shoulders, arms, and patting backs of others . The report indicated that both residents' care plans were updated and line of sight was to continue with family providing supervision during the afternoon and evening. R1's Nurse Progress Notes includes an entry on [DATE] at 3:10 PM, that the facility spoke to R1's physician regarding agitated aggressive behaviors, continued touching/reaching out physically to peers, physically combative with staff. R1's physician ordered to start hydroxyzine 25 MG (Milligrams) at bedtime for sleep and to improve mood and decrease behaviors, POA was in agreement with treatment plan. R3 was admitted to the facility on [DATE] and has a BIMS score of 2, which indicates, severe cognitive impairment. On [DATE] at 3:35PM, Surveyor interviewed CNA H (Certified Nursing Assistant) and asked what she could recall about what happened on [DATE] between R3 and R1. CNA H indicated R3 was sitting at the end of the table and R1 was by the exit door in the dayroom. CNA H indicated, I went to get him and he walks so fast, he came by like this. CNA demonstrated how and where R1 was moving in the dayroom. R3 had her elbows on the table with her hands together. CNA H continued, R1 walked by and touched her arm with the back of his hand and then went lower on the side of her breast with the back of his hand. I called his name and he looked up and smiled and kept walking toward the nurse's office, where SW I (Social Worker) was on the phone. Surveyor asked CNA H what she did to ensure R1 didn't go back by R3 again. CNA H indicated, he didn't go back by her, she would snap, we would have known, she told him, don't come by me again. Surveyor asked CNA H how she ensured R3 and other residents safety. CNA H indicated, we watched him (R1). Surveyor asked CNA H, how did you watch him. CNA H indicated, I was out here. Surveyor asked CNA H if she was with R3 or R1 one hundred percent of the time after the incident to know he didn't reapproach. CNA H indicated she wasn't with either of them one hundred percent of the time after it happened. Surveyor asked CNA H how then she knew he did not reapproach. CNA H indicated, we would have known, she would have yelled. On [DATE] at 9:52AM Surveyor interviewed SW I and was asked about the incident between R1 and R3 on [DATE]. SW I indicated, I do know I was back there at the time it happened. From my understanding it wasn't an intentful inappropriate touch. Surveyor asked SW I how she would know if it was intentional. SW I indicated, just because of the way she was sitting at the table with her arms on the table, her elbows were on the table. Where I was his (R1) back was to me and I saw him reach over and bend towards her. SW I demonstrated sitting in the chair and leaning towards floor. I didn't see him touch her, but we separated them. SW I indicated R1's back was to her. He was busy, active all day long, so I took him to the other hub. Surveyor asked SW I to clarify if R1 was sitting or walking by when he touched R3. SW I indicated, he was standing and he was walking by her. Surveyor asked SW I what was done to ensure resident safety after the incident between R1 and R3 on [DATE]. SW I indicated, they kept R1 separated. They kept R3 where she always is and kept R1 in the other hub. R1's son was here that night too, after the incident, and was with him, not sure exactly how long he stayed that night, but he usually stays until he's ready for bed. On [DATE], Surveyor interviewed LPN D, LPN E, RN F, LPN G, CNA J, and CNA K and all indicated their schedules include working on the memory care unit and were not aware of an incident between R3 and R1. On [DATE] at 9:20AM Surveyor interviewed DON B and asked how resident safety was ensured after the incident with R1 and R3. DON B indicated, staff and family were providing 1:1 with R1 the evening of the incident. Surveyor asked DON B if she was aware of what was done for R3. DON B indicated, I don't. DON B added, I do know ANHA C said R3 didn't remember the incident the next day and I haven't seen any changes, she's been at baseline. Surveyor asked DON B if there is documentation of monitoring R3. DON B indicated, they should have been documenting on daily acute charting for mood/behavior after. Surveyor requested copies of this charting. No documentation referenced by DON B was provided to surveyors. On [DATE] at 11:05AM Surveyor interviewed ANHA C and asked if all staff with the potential to care for R1 and R3 should be made aware of the incident so they are aware there is potential for continued contact? ANHA C indicated, yes. Surveyor asked ANHA C if she is aware of how and when staff were made aware of this incident. ANHA C indicated, when I was asking the question if they knew of any other residents being touched they would say, why are you asking me this and that would lead to informing them about who the incident was with. Surveyor asked ANHA C what was done immediately after the incident to protect R3 and other residents. ANHA C indicated she would have to check the care plan. On [DATE] at 9:40AM DON B showed surveyor on R3's care plan a revision made on [DATE] which states, Redirect from easily agitated residents to avoid negative behavior from others. Surveyor asked DON B if this intervention would be considered personalized for R3. DON B indicated, not really. Surveyor asked DON B if this statement is on other residents care plans. DON B indicated, probably. The care plan revision provided to the Surveyor was documented on [DATE], four days after the date of the incident. 44552 Example 2 R1's Nure Progress Note on [DATE] at 10:18 PM states, R1 was pacing in the unit. Staff had him in line of sight and was only about 3 feet from him at all times .staff redirected resident out of other rooms on the unit. After this he continues to be very close to female resident, he leaned in and kissed a resident on the cheek when talking with her. When staff attempted to intervene, R1 began to push, shove, grab and squeeze writer's hands. He threatened to hit this writer multiple times I am going to knock you out .Son was called twice, and he was here by 7:00 pm R1 did take his evening medicine with son present. Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report dated [DATE], states, in part, Time occurred: 07:00PM .Staff was walking with R1, R1 leaned over and kissed R2 on the cheek. R1 returned to their room with direct observation. Son in attendance. MD notified for clinical work up. R2 and family with no concerns .EXPLAIN what steps the entity took upon learning of the incident to protect the affected persons and others from further potential misconduct: Resident interviews-no concerns, staff interviews-no concerns, both resident care plans updated. Line of sight to continue. Family and staff providing 1:1 during the afternoon/evening hours when resident tends to wander more. Education for effective redirection. Referral made to MD for assessment and new orders. Follow up referral to MD with additional medication management. Nurse Progress Note on [DATE] at 10:01 PM, R1 was evaluated at the hospital due to behavior display on unit, adverse interactions with staff and peers, resident behavior display with swearing and agitative episodes. New order for Seroquel 12 MG at HS (hour of sleep) times 5 days. POA aware and in agreement with treatment plan. There is no evidnece of any new immediate interventions to protect residents from inappropriate interaction with R1. Nurse Progress Note on [DATE] at 7:43 AM indicates the facility contacted R1's physician requesting medication change, new order received for Seroquel 25 MG po BID. POA in agreement. There is no documentation indicating why this request was made. On [DATE] at 12:30 PM, LPN (Licensed Practical Nurse) G indicated she was the staff that was assisting R1 during the [DATE] incident. LPN G indicated she was walking with R1, R1 bent down and kissed R2 on the cheek. LPN G indicated she immediately stepped in between the two residents and redirected. R1 became mad and started yelling and swearing at LPN G. R2 was giggling. LPN G indicated that R1 and R2 will look for each other and seek each other out. LPN G indicated the incident happened so quickly. LPN G indicated R1's POA will come and sit with him. There is always one CNA and one nurse back in the Memory Care Unit, more recently there is now a 1:1 with R1 as well. LPN G indicated after the incident she ensured both residents were safe. LPN G indicated she ensured that R2 still felt safe, and she was doing different activities after incident. Example 3: Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report dated [DATE], states, in part, Time: 1:10 PM Brief Summary of Incident: Resident A (R1) observed in Resident B's (R2) room with Resident B's (R2) pants lowered. Nurse observed Resident A (R1) on opposite side of unit just prior to staff observing residents together. Residents families aware and just recently agreed to the two having a relationship as both have been seeking each other out for companionship. Briefly Describe the incident- Resident A (R1) observed in Resident B's (R2) room with Resident B's (R2) pants lowered, when Med Tech arrived Resident B (R2) said oops, pulled up their under garments and went over to their bed. Resident A (R1) was escorted out of the room. Families in agreement for residents to have a relationship with each other. BIMS score of Resident A (R1)- 2 BIMS score of Resident B (R2)- 1. Time frame of 3XXX,d+[DATE] minutes. DESCRIBE THE EFFECT that the incident had on the affected person, the person's reaction to the incident, and the reaction of others who witnessed the incident: Resident B (R2) has no ill effects. Resident B (R2) behaviors for seeking out Resident A (R1) have decreased and remains easily redirectable. EXPLAIN what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct: Residents separated immediately. Ensured safety of all residents DON and Administrator notified immediately. Resident A (R1) put on direct observation. Police notified. Resident A (R1) left facility for the weekend. Families notified. Interviewed staff- no new events, no concerns. Physician contacted for further review. Resident returned to facility Monday ,d+[DATE] at 10:30am and new intervention put into place of 1:1. On [DATE] at 1:30 PM, Surveyor spoke with Housekeeper R who was the first person to witness the [DATE] incident with R1 and R2. Housekeeper R indicated there was a strange noise, walked in to R2's bedroom, and saw the two residents. Housekeeper R indicated she saw R2 standing in front of R1, his hands on her breasts, R1 had his pants down, and it looked like R2 was pulling up her pants. Housekeeper R indicated she did not leave the room and yelled for assistance. Housekeeper R indicated that the Med Tech came and assisted with the situation. Housekeeper R indicated there were two staff in the Memory Care Unit at that time. Housekeeper R indicated there was a Med Tech and a CNA. The Med Tech was in another room charting and the CNA was assisting another resident. On [DATE] at 9:30AM, Med Tech S indicated she was one of the first staff to witness the [DATE] incident between R1 and R2. At 1:09PM she was completing charting in the charting/med room. She heard someone yell nurse, nurse, nurse. Med Tech S indicated she went to R2's bedroom, R1 was walking away and zipping his pants, R2 appeared to be pulling up her pants. R1 stated he was trying to pick up his hat and he attempted to go by R2. Housekeeper R stayed by R2. Med Tech S notified RN F. Surveyor asked who was assigned to keep R1 in line of sight? Med Tech S indicated all staff are responsible for keeping track of residents. Med Tech S indicated R1 and R2 had just finished lunch. Surveyor asked Med Tech S what residents were doing after the incident. Med Tech S indicated R1 and R2 were sitting across from each other at a table, holding hands, and smiling at each other. Med Tech S indicated staff were keeping an eye on them. At the time of the [DATE] incident, R1 was to be on line of sight supervision. Based on the description provided, R1 was not being provided with that supervision. R1's care plan was updated on [DATE] (3 days after the incident) to include 1 to 1 supervision. Review of documentation for provision of one to one for R1 from [DATE] at 10:30 AM through [DATE] notes assigned staff completing one to ones for R1 in 2 hour increments 24 hours a day. On [DATE] at 10:45 AM, CNA J indicated R1 must be in line of sight and just recently there is now a staff that is designated just for R1, so he is now a 1:1 at all times. CNA J indicated he was not working on [DATE]. On [DATE] at 10:50 AM, RN F indicated that R1 is now 1:1 and this means that he must be within arms reach of a staff member that is assigned to him. RN F indicated for all resident-to-resident altercations staff must separate the residents, ensure a safe environment, and immediately report the incident. RN F indicated management discusses interventions and then will relay what the interventions are to staff. RN F indicated nursing staff are not involved in deciding appropriate interventions. RN F indicated they will assign extra staff to ensure safety for residents. RN F indicated she was the staff that was with R1 on [DATE]. RN F indicated she was watching and keeping R1 in line of sight on [DATE] from around 6:45AM to 11:40AM. RN F indicated the DON (Director of Nursing) called and had her leave the Memory Care Unit to assist elsewhere. RN F indicated she didn't ask any other staff to keep R1 in line of sight when she left the area. RN F indicated all of the staff in the Memory Care Unit are responsible for ensuring resident safety and supervision. 38882 Example 4: On [DATE] at 1:45 PM Surveyor observed R1 wiping tables with MM U (Maintenance Man). R2 ducked under the mesh stop sign in her doorway and entered the dining area. R1 stopped wiping tables and walked towards R2. MM U continued to finish wiping the table having his back to R1 and R2. R1 and R2 shook hands and R1 continued to hold R2's hand in his cupped hands. Surveyor asked MM U if he was working directly with R1. MM U turned around and yelled, Hey don't do that. Do not do that. No touching. MM U used his hand to separate R1's and R2's hands and then said, You cannot touch other residents. MM U indicated he is assigned to be one on one with R1 until 2:00 PM and this means he is to keep R1 from doing anything inappropriate with other residents. On [DATE] at 2:05 PM during an interview LPN D and LPN G indicated the expectation for one on one is to stay nearby and be available to intervene if needed. LPN G indicated she tries to give R1 some space so she doesn't make him angry. LPN D indicated one on one staff must always have eyes on R1 and having your back to R1 is not one on one supervision. LPN G voiced to be in agreement. On [DATE] at 2:22 PM DON B indicated the staff assigned to be one on one with R1 is to be within arms reach of him at all times and if he wants to shake the hand of other residents in the common area she would allow him to do so. Surveyor asked about hand holding. DON B indicated residents have the right to intimacy. Surveyor asked DON B if one to one staff should have their backs turned to R1 when providing supervision. DON B indicated no. DON B indicated R1 should not be holding R2's hand, given the seriousness of the situation. Example 5: On [DATE] at 7:15 AM to 8:15 AM Surveyor observed SW I sitting at a table completing paperwork and working on her laptop while R1 was approximately 15 feet away removing lights and ornaments off of the Christmas tree in the facility's main entrance lounge. R9 was resting in a chair approximately 15 feet away from R1 in the opposite direction of SW I. Surveyor observed DON B walk through area and stop to talk with SW I at the table. Both staff were approximately 15 feet away from R1 and 30 feet away from R9. SW I did not stay within an arms reach and also did not keep R1 within sight as she turned to face DON B and while she completed her work. Example 6: On [DATE] at 8:16 AM to 8:43 AM Surveyor observed R1 sitting at a table eating breakfast. SW I was going table to table offering coffee and other food items to other residents throughout the dining room. There was a distance of up to 30 feet from her and R1. SW I also left the room and the unit to retrieve coffee and other food items while R1 was out of her line of sight and not within arms length or 1:1. Some of this time CNA J was within arms reach of R1 while he assisted another resident with her meal, but at times R1 did not have a staff member within arms reach of him. Example 7: On [DATE] at 8:47AM Surveyors observed SW I, R1, R8, R9, and R10 in the main entrance lounge. R1 was working on removing the Christmas lights off of the Christmas tree. R9 and R10 were playing cards at a table. R8 was working on a jigsaw puzzle. SW I was assigned to be 1 on 1 with R1. SW I walked out of the room into a nearby office. SW I was about 30 feet away from R1. R1 was about 15 feet away from the other 3 residents in the room. SW I was out of the room for over one minute. During the minute Surveyor observed ANHA C in the window of the main office talking to an unknown person. On [DATE] at 9:41 AM during an interview ANHA C indicated her expectation of 1 to 1 one is within arms reach and available to intervene immediately if needed. ANHA C indicated she too witnessed SW I leave the area while she was to be 1 to 1 with R1. Surveyor asked if SW I was in arms reach of R1. ANHA C indicated she was not. Surveyor asked if SW I was in a position to intervene immediately if R1 inappropriately approached any of the other 3 residents. ANHA C indicated she was not. Surveyor asked if ANHA C was in arms reach of R1 and if she was in a position to immediately intervene if R1 inappropriately interacted with the other 3 residents in the room. ANHA C indicated she was not an arm's length away from R1 and she was not in a position to immediately intervene if necessary. ANHA C indicated she would educate SW I immediately on the facility's expectations of 1 to 1.

Based on interview and record review the facility failed to ensure residents were free from abuse. R1 had a known history of inappropriately touching female residents. R1 was observed touching R2 and R3 in an inappropriate manner. On 12/1/22 R1 was witnessed to touch R3's arm and breast. The facility failed to: perform an assessment of R3; document monitoringm of R3's for behavior changes; ensure R3 and other resident safety after incident; and update R3's care plan timely. On 12/2/22, R1 was witnessed to kiss R2. On 12/10/22, R1's care plan was not followed and R1 was unsupervised and witnessed by staff in R2's room with R2's pants down. The facility was aware of R1 behaviors of inappropriate physical/sexual contact with other residents. R1 is unable to consent to sexual activity based on his cognitive status, R1 had inappropriate contact with other residents, the facility did not complete a sexual consent assessment for R1. The facility failed to protect others from abuse by R1 on 12/1/22, 12/2/22 and 12/10/22. The facility's failure to provide adequate protection from abuse from R1 to R2 and R3 and other residents, created a finding of Immediate Jeopardy which began on 12/1/22. NHA A (Nursing Home Administrator) was notified of the immediate jeopardy on 12/20/22 at 4:41 PM. The Immediate Jeopardy was not removed at the conclusion of survey. Evidenced by: R1 was admitted to the facility on [DATE] with diagnoses including: Mild cognitive impairment of uncertain etiology, age related cognitive behaviors, and bilateral hearing loss. On 11/18/22, a diagnosis of Alzheimer's dementia was added to R1's record by R1's physician. On 12/5/22, R1 was diagnosed with Dementia with associated psychotic-agitated behavior. R1 has an APOAHC (Activated Power of Attorney for Health Care). On 11/15/22, R1's admission MDS (Minimum Data Set) assessment notes a BIMS (Brief Interview for Mental Status) score of 2, indicating severe cognitive impairment. Section E of the MDS notes R1 wandering behaviors occurred daily. Section G notes R1 is independent in transfers, ambulation, and locomotion on the unit. R1's Care Plan from 11/25/22 included, Keep resident in line of sight when up, this approach was discontinued on R1's Care Plan on 12/13/22. R1's Care Plan notes; (dated 11/10/22) Problem: need for appropriate sexual expression/display of affection, (dated 12/13/22) Approaches (dated 12/13/22): ~Nurses-One to one, redirect immediately, be mindful of personal space and uninvited entrances into others space ~Monitor personal boundaries and document redirecting needed and any inappropriate behaviors, document interventions, involve family ~Provide ample 1:1 (one to one) and/or independent activities with meaningful tasks (see activity care plan), social distance from opposite sex (i.e. provide appropriate boundaries between opposite sex). ~Monitor/intervene immediately prior to socially inappropriate touching and close talking to others, remind of personal boundaries. ~If defiant/aggressive behavior occurs, try reality orientation, involve family, validate concerns and emotions and remind of appropriate behaviors/actions . ~Nurse aide-one to one, redirect immediately, report immediately to nurse . Review of R1 record notes R1 specific behaviors are monitored each shift as follows: -On 11/8/22, the facility monitored R1 for exit seeking (R1 is a known wanderer and is independent in ambulation), with these behaviors documented as occurring 0-60 times per day 11/22/22-12/19/22. -On 11/22/22, the facility added monitoring R1 for behaviors of socially inappropriate touching of peers. Documentation shows these behaviors occurred 0-68 times per day between 11/22/22-12/19/22. -On 11/22/22, the facility added monitoring R1 for behaviors of socially inappropriate touching or sexual comments to staff. Documentation shows these behaviors occurred 0-50 times per day between 11/22/22-12/19/22. -On 12/5/22, the facility added monitoring R1 for targeted behavior of Persistent anger: pushing, slapping or other aggressive behavior toward staff. Socially inappropriate/disruptive shoving furniture, kicking doors. Documentation shows these behaviors occurring 0-58 times per day from 12/5/22-12/19/22. Review of R1's Nursing Notes include in part: ~On 12/1/22 at 8:36 PM, Holding hands with another resident. Leans in close to hear what is being said . Sitting close to same resident that he was holding hands with. Needed reminders that 'we need to keep our hands to our self.' Son was here and stayed for awhile and also aided in keeping distance. Was redirected and good spirits. Started on Hydroxyzine this evening. No attempts to touch others just wanting to hold their hands. Will continue to monitor. ~On 12/2/22 at 10:18 PM, R1 was pacing in the unit. Staff had him in line of sight and was only about 3 feet from him at all times during this .staff redirected resident out of other rooms on the unit. After this he continues to be very close to female resident, he leaned in and kissed a resident on the cheek when talking with her. When staff attempted to intervene, R1 began to push, shove, grab and squeeze writer's hands. He threatened to hit this writer multiple times 'I am going to knock you out' .Son was called twice, and he was here by 7:00 pm .did take his evening medicine with son present. The facility submitted a self-report to the State Agency regarding R1 kissing R2 on 12/2/22. R1's care plan was not immediatley updated, there is no documentation of new interventions to protect R1 from having contact with R2 or other residents immediately put in place after this event. 39849 Example 1: R3 was admitted to the facility on [DATE] with diagnoses that include, in part: Alzheimer's disease; Unspecified Dementia; Restlessness and agitation; Major Depressive Disorder; Vascular dementia; and Need for Continuous Supervision. R3's most recent MDS (Minimum Data Set) with a target date of 11/18/22, documents a BIMS (Brief Interview of Mental Status) score of 2, which indicates, severe cognitive impairment. R3's CNA (Certified Nursing Assistant) Care Card dated 12/19/22, includes, in part: *Ensure to alert nurse of any exit attempts. *Can be agitated as day progresses. *Stop sign on door as she becomes upset when other residents wander into her room. *Altered interpersonal response to others. *Redirect from easily agitated residents to avoid negative behavior from others. R3's care plan includes, in part: *9/2/22: Special Care Remarks: Ensure to alert nurse of any exit attempt immediately. *12/5/22: Special Care Remarks: Can become agitated as the day progresses .Stop sign on door as she becomes upset when other residents wander into her room .Redirect from easily agitated residents to avoid negative behavior from others. Review of the Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, with a Report Submitted Date of 12/1/22, indicates the following: Summary of Incident: Allegation Type: Abuse: Hitting, slapping, threats of harm, assault, humiliation .Brief Summary of Incident: Resident A (R1) reached out toward Resident B (R3) and touched them on the arm and also touched their breast. Resident A (R1) has a tendency toward physical contact (rubbing shoulders/arms, patting backs) and their hand has slipped. Review of the Misconduct Incident Report, with a Report Submitted Date of 12/8/22, documents the following: .Summary of Incident: Is date and time when occurred known? No Date discovered: 12/1/22. Briefly describe the incident .Resident A (R1) reached out toward Resident B (R3) and touched them in the arm and inadvertently touched the side of their breast with the back of their hand. Resident A (R1) has a tendency toward physical contact which may include rubbing shoulders, arms, and patting backs of others. Describe the effect . Resident B (R3) has no recollection of event nor change in mood or affect. Explain what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct .Interviews of residents - no concerns. Interviews of staff - no concerns. Both residents care plans updated. Line of sight to continue. Family and staff providing 1:1 during the afternoon/evening hours when resident tends to wander more. Education for effective redirection. Referral made to MD for assessment and new orders . Review of R3's nursing notes for 12/1/22 through 12/4/22 show no documentation other than vital signs and pain rating. On 12/20/22 at 8:20AM Surveyor interviewed DON B (Director of Nursing) and showed DON B the nursing notes in the facility's electronic health record. Surveyor asked DON B if this was all the charting for R1 or if there is documentation elsewhere, as there were no actual assessments, documentation of the incident, notes about the resident, just the vitals and pain ratings. DON B indicated, No, that is what's there, what you're seeing is what there is. Further record review shows no specific documentation for the following: *Assessment of R3 on 12/1/22. *Immediate Interventions specific for R3. *Post sexual abuse allegation behavior monitoring for R3. Of note, R3's Care plan update was not completed until 12/5/22, four days after the initial incident. On 12/19/22 at 3:35PM, Surveyor interviewed CNA H (Certified Nursing Assistant) and asked what she could recall about what happened on 12/1/22 between R3 and R1. CNA H indicated R3 was sitting at the end of the table and R1 was by the exit door in the dayroom. CNA H indicated, I went to get him and he walks so fast, he came by like this. CNA demonstrated how and were R1 was moving in the dayroom. R3 had her elbows on the table with her hands together. CNA H continued, R1 walked by and touched her arm with the back of his hand and them went lower on the side of her breast with the back of his hand. I called his name and he looked up and smiled and kept walking toward the nurse's office, where SW I (Social Worker) was on the phone. Surveyor asked CNA H what she did next. CNA H indicated she reported the incident to SW I. CNA H indicated that she also reported to LPN E (Licnsed Practical Nurse) right away. Surveyor asked CNA H if she was given any instructions. CNA H indicated, she didn't recall. CNA H indicated R1 touched R3 on the side of her breast with the back of his hand. Surveyor asked CNA H what she did to ensure R3 was safe. CNA H indicated, I went and asked her how she was and she said she was fine but that she didn't trust him (R1). Surveyor asked CNA H what was done to ensure R1 didn't go back by R3 again. CNA H indicated, he didn't go back by her, she would snap, we would have known, she told him, don't come by me again. Surveyor asked CNA H how she ensured R3 and other residents were safe. CNA H indicated, we watched him (R1). Surveyor asked CNA H, how did you watch him. CNA H indicated, I was out here. Surveyor asked CNA H, you never went into a resident room that night. CNA H indicated, well, the nurse was here too. Surveyor asked CNA H if she was with R3 or R1 one hundred percent of the time after the incident to know he didn't reapproach. CNA H indicated she wasn't with either of them one hundred percent of the time after it happened. Surveyor asked CNA H how then she knew he did not reapproach. CNA H indicated, we would have known, she (R3) would have yelled. On 12/19/22 at 4:59PM, Surveyor interviewed LPN E and asked if she normally works on the memory care unit. LPN E indicated, yes, we have a few patients on the other wing as well. Surveyor asked LPN E if she recalled working when an incident between R3 and R1 occurred. LPN E indicated, no. Surveyor asked LPN E if she recalled anyone informing her of an incident where R1 may have touched R3's breast. LPN E indicated, no, I don't recall that. LPN E indicated she does not believe she was working 12/1/22, however, did not have her schedule at the time to of this call to verify. Of note, the schedule provided by the facility showed a v next to LPN E's name, which surveyor was informed indicates vacation. It is unclear which nursing staff CNA H reported the incident to. On 12/20/22 at 9:52AM Surveyor interviewed SW I and was asked about the incident between R1 and R3 on 12/1/22. SW I indicated, I do know I was back there at the time it happened. From my understanding it wasn't an intentful inappropriate touch. Surveyor asked SW I how she would know if it was intentional. SW I indicated, just because of the way she was sitting at the table with her arms on the table, her elbows were on the table. Where I was his (R1) back was to me and I saw him reach over and bend towards her. SW I demonstrated sitting in the chair and leaning towards floor. I didn't see him touch her, but we separated them. SW I indicated R1's back was to her. He was busy, active all day long, so I took him to the other hub. Surveyor asked SW I to clarify if R1 was sitting or walking by when he touched R3. SW I indicated, he was standing and he was walking by her. Surveyor asked if anyone reported to her that R1 had touched R3. SW I indicated, I can't even answer that, I don't know what the terms were when reported to me that were used. If he did or didn't touch her breast. Surveyor asked SW I what she reported to DON B that would make them reference in the self-report that R3's breast was touched. SW I indicated, I don't remember. Surveyor asked SW I how long she was in the memory care unit after the incident happened. SW I indicated, I don't know when I left, could have been ten minutes, could have been a half hour. Surveyor asked SW I what was done to ensure resident safety after the incident. SW I indicated, they kept R1 separated. They kept R3 where she always is and kept R1 in the other hub. R1's son was here that night too, after the incident, and was with him, not sure exactly how long he stayed that night, but he usually stays until R1's ready for bed. Surveyor asked SW I if R1's son is his POA. SW I indicated, yes. Surveyor asked SW I if R1's son was informed of the incident. SW I indicated, I don't know. Surveyor asked SW I if an incident like this should be reported to the POA. SW I indicated, yes. Surveyor asked SW I if she remembered when she reported this incident to DON B. SW I indicated, no. Surveyor asked SW I if she had any notes or a soft file that may include that information. SW I indicated, no. Surveyor asked SW I if she documented any of the information about the incident in the chart. SW I indicated, no. Surveyor asked SW I if she should have documented in the chart. SW I indicated, yeah, probably. Surveyor asked SW I if she is trained to report incidents like this immediately. SW I indicated, yes, it was still unclear if it was breast or not. Surveyor asked SW I if there is a potential incident where a resident could have touched another resident's breast, should it be reported immediately so it can be investigated. SW I indicated, yes. On 12/19/22 at approximately 12:00PM, Surveyor interviewed RN F (Registered Nurse) and asked if she normally works on the memory care unit. RN F indicated she works 2 days on the memory care unit and 3 days on the other units. Surveyor asked RN F if she was aware of any inappropriate touching between R3 and R1. RN F indicated no. Surveyor asked RN F if she was aware of any other interventions in place for R3 as of 12/1/22 other than the stop sign on her room. RN F indicated, not anything different than the last few weeks. Honestly, I didn't know anything happened between R1 and R3. RN F added, R3 sits with R2 and another resident and the three of them are kind of a thing, they have a friendship and sit at tables and visit. Surveyor asked RN F if R3 ever approaches R1 or if R1 ever approaches R3. RN F indicated, no. RN F indicated R1 had been separated and after that happened he went home with his son on 12/10/22 and 12/11/22 and came back on Monday 12/12/22. I didn't work with him until that Friday 12/16/22 and he was 1:1 then. Surveyor asked RN F why R1 was separated. RN F indicated there was an incident on 12/10/22 and so his son took him home because of the incident. (See example 2.) On 12/19/22 at 4:40PM Surveyor interviewed LPN D and asked if he recalled working 12/1/22 on the memory care unit and if he had any information about an incident between R3 and R1. LPN D indicated he would have been gone by 2pm. I don't recall an incident between R3 and R1. Surveyor asked LPN D if anyone had informed him of an incident between R3 and R1. LPN D indicated he had never been told of one. LPN D indicated it may have been LPN E it was reported to. Surveyor asked LPN D if he normally works on the memory care unit. LPN D indicated yes and that he is the dementia care coordinator. Surveyor asked LPN D if he would have expected to be informed of an incident between residents as the coordinator. LPN D indicated, yes. Surveyor asked LPN D if he was aware of any specific interventions that were in place for R1 on 12/1/22. LPN D indicated, we always keep an eye on him but I don't recall if there was anything specific on that date. I know there was 1:1 after another incident. On 12/19/22 Surveyor interviewed LPN G, who indicated she was the Clinical Nurse Manager, and asked how often she works on the memory care unit. LPN G indicated, it depends on when the nurse isn't there. I'll be working there tonight. Surveyor asked LPN G if she was aware of an incident between R3 and R1. LPN G indicated, I know she (R3) doesn't like him by her. Surveyor asked LPN G how she knows this. LPN G indicated, because when he (R1) comes by her she would say get away from me. Surveyor asked LPN G how long ago she had witnessed this. LPN G indicated, not in the last week or so that I've heard. On 12/19/22 at 11:32AM, Surveyor interviewed CNA J and asked if he was aware of any incidents between R3 and R1. CNA J indicated, nothing about R3 and R1. Only R1 and R2 (See Example 2). CNA J added that sometimes there is only one CNA on the unit and one nurse and that R1 is 1:1. Surveyor asked CNA J how 1:1 is completed if they have to go into a room to assist another resident. CNA J indicated, someone comes back now. Surveyor asked CNA J how long they have been sending someone to help in those instances. CNA J indicated, the last couple days. Surveyor asked CNA J if he had been given any guidance on interventions or things to do for R3. CNA J indicated, no. On 12/19/22 at 10:38AM Surveyor interviewed CNA K and asked if she has worked with R1 and R3. CNA K indicated, yes. Surveyor asked CNA K if she was aware of a incident between R1 and R3. CNA K indicated she was not. Surveyor asked CNA K if she was given any education on abuse recently. CNA K indicated last week ANHA C (Assistant Nursing Home Administrator) called her pertaining to R1 being 1:1. CNA K indicated she was informed that R1 is 1:1 and staff is to be with him at certain times and it's usually two hour increments. Surveyor asked CNA K if she was given guidelines on anything for R3. CNA K indicated she worked on the memory care unit yesterday and didn't see anything specific, unless she missed it. On 12/19/22 at 3:23PM, ANHA C provided surveyor with a three page typed document that notes Interviews conducted on 12/2/22, at the top. ANHA C indicated, the document is staff interviews. The document contains 10 names with times after the names and the following 3 questions under each name: Have you seen R1 touch any other residents inappropriately? Has he touched you on the buttocks, groin, or chest?; What would you do if that happened? There is no information on the document of who the listed names are; signatures from the interviewees indicating they provided this information; or information on who the other resident was that was involved in the incident with R1. Surveyor asked ANHA C what self-report these are in relation too. ANHA C indicted they were from the incident with R3 and R1. Surveyor asked ANHA C how this would be known as neither R3's name nor the incident date was included on the document. ANHA C indicated, from the date and pointed to the 12/2/22 date at the top of the document. ANHA C also provided a diagram that was drawn on notebook paper and states it is showing the path of the CNA (Certified Nursing Assistant) walking with R1 and where R3 was sitting. ANHA C indicates, the CNA was CNA H and that as R1 was walking by and that is when the incident happened. On 12/20/22 at 12:45PM ANHA C provided Surveyor with a typed document and indicated this was a witness statement from CNA H. CNA H's name is typed at the top with the date and time of 12/1/22 @ 5:55pm. The statement notes the following: CNA H was in MCU (Memory Care Unit) walking to the left of R1. R1 was walking by R3, who was sitting at the table. When walking by he went to touch her and touched her in the arm and brushed against her breast and continued walking. He went to the opposite side of the unit. CNA ensured safety of residents and made sure R3 was ok. Of note, there is no signature or indication from CNA H, on the document, that this is the statement she provided. On 12/20/22 at 11:05AM Surveyor interviewed ANHA C and asked if all staff with the potential to care for R1 and R3 should be made aware of the incident so they are aware there is potential for continued contact? ANHA C indicated, yes. Surveyor asked ANHA C if she is aware of how and when staff were made aware of this incident. ANHA C indicated, when I was asking the question if they knew of any other residents being touched they would say, why are you asking me this and that would lead to informing them about who the incident was with. Surveyor asked ANHA C what was done immediately after the incident to protect R3 and other residents. ANHA C indicated she would have to check the care plan. On 12/20/22 at 9:20AM Surveyor interviewed DON B and asked how resident safety was ensured after the incident with R1 and R3. DON B indicated she would have to check. Surveyor offered a copy of the self-report for review to DON B. DON B asked, this is the full report you were given. Surveyor indicated, yes. Surveyor asked DON B if there was more that wasn't provided. DON B indicated, I don't know. DON B indicated staff and family were providing 1:1 with R1 the evening of the incident. Surveyor asked DON B if she was aware of what was done for R3. DON B indicated, I don't. DON B added, I do know ANHA C said R3 didn't remember the incident the next day and I haven't seen any changes, she's been at baseline. Surveyor asked DON B if there is documentation of monitoring R3. DON B indicated they should have been documenting on daily acute charting for mood/behavior after. Surveyor requested copies of this charting. Surveyor asked DON B if a physical assessment was performed on R3 or other residents, like a skin sweep, to ensure their were no signs or symptoms of abuse. DON B indicated, not to my knowledge. Surveyor asked DON B if she would expect something like that to be done for residents who couldn't tell you if they had been abused. DON B indicated because R1 was in line of site, I'm confident he hadn't abused anyone else. Surveyor asked DON B if R3 should have had a skin/overall assessment. DON B indicated, probably, but it was such a light touch. Surveyor asked DON B how they could know if he had done anything to her, that may not have been witnessed, if an assessment wasn't done. DON B indicated, because he was on line of site. Surveyor asked DON B if she was sure he was in line of site at all times. DON B indicated, yes, I'm confident, I'm back there a lot. Surveyor asked DON B if R3's care plan was updated after the incident. DON B indicated, I know there was a change but I can't remember. Surveyor asked DON B for follow up on the care plan. Surveyor asked DON B what the overall process is for an abuse investigation. DON B indicated the expectation if is its alleged or actual is that it gets reported immediately. Generally the next closest supervisor, so usually the charge nurse, but I have had employees go directly to the social worker, me, the NHA. So if it goes to a social worker or charge nurse then it comes to me and I go to NHA A. Surveyor asked DON B if she goes directly to NHA A. DON B indicated I have been co-reporting to NHA A and ANHA C. DON B indicated, once noted, first thing is to address safety concern and remove resident. It also depends on the situation; first thing is to maintain safety whatever that looks like for that incident; then get staff statements. Surveyor asked if staff write their own witness statements. DON B indicated, no, our corporate philosophy is to have us talk to the staff and transcribe their statement. Surveyor asked DON B if those should be in the investigation. DON B indicated, yes, exactly. Surveyor asked DON B if it should be a statement and not just questions they ask the staff. DON B indicated, typically that's not me. If it's the person that witnessed it, I would expect a statement. Typically, ANHA C and NHA A are leads, not sure if it is ANHA C or NHA A at this point. Ancillary staff may be just questions. Surveyor asked DON B what happens next. DON B indicated, then we start working through the algorithm to see if it's reportable or not, do we remove employees, things like that. If reportable we start the reporting process. If not, we would look through it for what else is needed for that particular incident: audits; changes to care plans; further investigation; education. Surveyor asked DON B if this incident should be documented in either R1's or R3's chart or both. DON B indicated, it's going to depend on what it is. Surveyor asked DON B if she could elaborate. DON B indicated, typically what we enter into ECS (Facility's electronic health record) is what is pertaining to the resident's health. So if there is something that is needed like an assessment, behavior tracking/monitoring, you would see that but otherwise the incident itself would be on paper in a file. Surveyor asked DON B what time the incident happened. DON B indicated, I was under the impression it occurred between 4:30pm and 5:00pm. Surveyor asked DON B how she knew the time of the incident. DON B indicated, because SW I informed me of the incident. I was not informed of the incident until the next morning. Of note, no documentation referenced by DON B was provided to surveyors. On 12/20/22 at 9:40AM DON B showed surveyor on R3's care plan a revision made on 12/5/22 that she had placed brackets around on a paper copy. The information in brackets, notes: Redirect from easily agitated residents to avoid negative behavior from others. Surveyor asked DON B if this intervention would be considered personalized for R3. DON B indicated, not really. Surveyor asked DON B if this statement is on other residents care plans. DON B indicated, probably. On 12/19/22 at 2:45PM 45PM Surveyor interviewed ANHA C (Assistant Nursing Home Administrator) regarding the process for completion of self-reports. ANHA C indicated, with any self-report for potential abuse, resident to resident, anything that could fall under abuse we have the flow chart we use for, is it willful, is it not. Surveyor asked ANHA C if she used the flowchart with the 3 self-report investigations. ANHA C indicated, I believe we did with R3, I will have to look before I can give an answer. Surveyor requested ANHA C to provide the flow charts used for the investigations. On 12/19/22 at 3:30PM, ANHA C notified Surveyor that no flowsheets were completed for the resident to resident self-reports. On 12/20/22 at 11:05AM Surveyor interviewed ANHA C and asked what is done during an abuse investigation if the resident is non-interviewable. ANHA C indicated, we would contact families, let them know the situation, ask families where they would like us to go with that situation. Surveyor asked ANHA C what she meant by this. ANHA C indicated, if they want police contacted. Surveyor asked ANHA C if she leaves it up to the family to decide if police are contacted. ANHA C indicated, in certain situations. Surveyor asked ANHA C if there were further things that are done for the non-interviewable residents. ANHA C indicated, we interview staff to see if other residents have been affected. We would still interview the non-interviewable residents to ask if they feel safe, if they feel comfortable with housemates, I still would try to interview. We watch for signs of changes in affect, eating, changes in day to day participation, mood. Surveyor asked ANHA C if she would expect that type of monitoring to be documented. ANHA C indicated, yes, I would. Surveyor asked ANHA C if she would expect staff to perform skin assessments to see if non-interviewable residents have any signs of concerning areas for abuse that they may not be able to verbalize. ANHA C indicated, yes. Surveyor asked ANHA C if those should be documented. ANHA C indicated, yes. Surveyor asked ANHA C if she would expect the resident who has the alleged abuse happen to, to have a skin assessment. ANHA C indicated, yes. Surveyor asked ANHA C if an investigation is completed without items such as: assessments of residents; the time the NHA is notified; complete staff education, do you have all the key components of a thorough investigation. ANHA C indicated, no. Of note, no further information or documentation regarding monitoring for R3 after the incident was provided to the surveyor. 44552 Example 2: R2 was admitted to the facility on [DATE] with a diagnoses including Dementia, Major Depressive Disorder, Anxiety Disorder, Acute Stress Reaction, and Age-Related Cognitive Decline. R2's most recent MDS with ARD (Assessment Reference Date) of 9/23/22, indicated R2's cognition was severely impaired with a BIMS (Brief Interview for Mental Status) score of 01 out of 15. R2's CNA Assignment Sheet, dated 12/19/22, indicates staff are to alert nurse of any exit attempts immediately. If she becomes upset with others provide her a safe quiet place to allow her to vent. STOP sign on door as she gets agitated when others wander into her room, maintain social distancing when in common areas to reduce risk of altered interpersonal response to others .Maintain social distancing when in common areas to reduce risk of altered interpersonal response to others. Redirect from easily agitated residents to avoid negative behavior from others. DO NOT allow resident to hold hands, hug, kiss or otherwise be generally affectionate with opposite sex. Should always be supervised in a common area. Redirect as needed. R2's Comprehensive Care Plan includes, in part, 12/13/22 PROBLEM: Resident seeking opposite sex attention with or without intent. Approaches included Nurses- redirect, engage and encourage activity participation, provide independent activities, utilize daily itinerary, monitor exit seeking, social distance from male resident, document anxiety and tearful moments, report inappropriate/concerning behaviors to DON/Administrator immediately. Ensure 1:1 at all time with male resident that she may be seeing to provide well being and dignity for all involved, intervene as needed. Nurse Aide- redirect, engage and encourage activity participation, provide independent activities, utilize daily itinerary, monitor exit seeking, social distance from male resident, document anxiety and tearful moments report inappropriate/concerning behaviors to charge nurse, and DON/Administrator immediately. Ensure 1:1 at all time with male resident that she may be seeking to provide well being and dignity for all involved, intervene as needed. 12/13/22 Maintain appropriate display of affection in social setting, maintain personal dignity, continue with quality of life, no episodes of inappropriate sexual behaviors. 12/9/22 Special Care Remarks: May allow resident to hold hands, hug, kiss or otherwise be generally affectionate with R1 per POA, this should always be supervised in a common area. A progess note from 1 [TRUNCATED]

Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents (R1) reviewed for wandering and elopement potential. R1 is severely cognitively impaired and has an Activated Power of Attorney for Health Care )(APOAHC). R1 has attempted to elope from the facility every day, and sometimes multiple times per day. R1 eloped from the facility on 8/12/22. R1 was missing for one and a half hours with the facility staff unable to locate R1. The facility made no changes in R1's Care Plan to prevent elopement or provide increased supervision. An alarmed door was found with the alarm disabled during the survey on 9/1/22. The facility's failure to provide adequate supervision to R1 and ensure all the alarmed doors were armed created a finding of Immediate Jeopardy which began on 8/12/22. NHA A (Nursing Home Administrator) was notified of the immediate jeopardy on 9/2/22 at 8:50 AM. The Immediate Jeopardy was removed on 9/2/22, however the deficient practice continues at a scope/severity of D (potential for harm/isolated) as the facility implements its removal plan. This is evidenced by: The facility policy entitled Elopement and Wandering Management revision dated 8/22, includes: *Always respond immediately to any activated door alarms. *When a resident is found to have new or potential elopement behaviors, this will be documented in the Nurses Notes . *Appropriate alert systems will be activated 24 hours per day/7 days per week. All door alarms and magnets will be routinely inspected as per facility preventative maintenance policy and the manufactures' directions. R1, who is [AGE] years old, was admitted to the facility on [DATE] with a diagnosis of [CONDITION(S)] with behavior disturbance. R1 has a Brief Interview for Mental Status (BIMS) of 4, which indicates she is severely cognitively impaired. R1 is independent with her ambulation. R1 is a resident on an alarmed memory care unit (MCU). R1's Elopement and Wandering Care Plan undated, includes: *Always respond immediately to any activated door alarms. *Approach R1 in a calm, reassuring manner. *Use redirection first, offer a diversional activity or use conversation to attempt to gain R1's cooperation. *Engage R1 in hands on meaningful activities daily. *Redirect R1 when around negative company. *Redirect when notice of over stimulation begins. *Offer R1 realistic baby doll or time in sensory room. *Redirect from exit areas and continue to encourage positive engaging activities. *Ask R1 where is attempting to do/go? Redirect R1, stay with her if she is exit seeking. *R1 was a care giver and will go to where she hears another resident's calling out. R1's Elopement and Wandering Care Plan dated 8/12/22, includes: *Always respond immediately to any activated door alarms. *Approach R1 in a calm, reassuring manner. *Use redirection first, offer a diversional activity or use conversation to attempt to gain R1's cooperation. *Engage R1 in hands on meaningful activities daily. *Redirect R1 when around negative company. *Redirect when notice of over stimulation begins. *Offer R1 realistic baby doll or time in sensory room. *Redirect from exit areas and continue to encourage positive engaging activities. *Ask R1 where is attempting to do/go? Redirect R1, stay with her if she is exit seeking. *R1 was a care giver and will go to where she hears other resident's calling out. The original undated Elopement and Wandering Care Plan did have the following approaches struck out: *Avoid arguing with R1. *Do not say You can't or You have to. It's important to note the struck-out sentences are the only difference in the original undated Elopement and Wandering Notification Care Plan and the 8/12/22 Elopement and Wandering Notification Care Plan. R1's Care Plan dated 12/14/21 includes Problem: Potential for Elopement and includes multiple diversional activities for staff to engage R1 in. Her Care Plan includes, It is helpful maintain a positive attitude with uplifting company and to avoid exit seeking. R1's Care Plan dated 8/12/22 includes: *Always respond immediately to any activated door alarms; do not turn off the alarm if responding alone; approach R1 in a calm, reassuring manner, approach R1 1:1 and discourage large numbers of staff around her as not to overwhelm her. Use redirection first, offer a diversional activity or use conversation to attempt to gain R1's cooperation. Ask R1 where is attempting to do/go? Redirect R1, stay with her if she is exit seeking. R1's Care Plan dated 8/18/22 includes: *Engage R1 in hands on meaningful activities daily, offer simple yet time consuming tasks for her to do. *Encourage R1 to be in a social group like setting away from the entrance of her bedroom door. Involve R1 by asking her to help with folding clothes with her peers. *Resident will go to the exit doors and open them, redirect as allows or stay with her. Surveyor reviewed R1's behavior documentation. June 2022 - R1 attempted to elope every day. On the PM shift there were 3 days when R1 attempted to elope greater than 15 times, and one day when R1 made 25 attempts to elope. July 2022 - R1 attempted to elope every day. On the PM shift, there were 15 days when R1 attempted to elope greater than 20 times, and two days R1 made 45 attempts to elope. August 2022 - R1 attempted to elope every day. On the PM shift, there were 13 days when R1 attempted to elope 20 times or greater. Review of the Nursing/Progress notes on 8/12/22 include at approximately 4:55 PM, LPN F (Licensed Practical Nurse) was passing supper trays and noted R1 was not at the supper table in the dining room. Checked R1's room and noted resident not in room. Checked all rooms in unit and resident not found. Alerted CNA G (Certified Nurse Assistant) and AA E (Activity Assistant). AA E stated she placed R1 at dining table after coming inside from previous activity done outside on patio. LPN F went outside building and searched for R1 while searching perimeter of building. At 5:15 PM, LPN F called 911 and reported R1 missing .Several staff outside calling R1's name and walking further outside building perimeter for R1. NHA A, ANHA D (Assistant Nursing Home Administrator), and SW H (Social Worker) notified and looking for R1 .Guardian notified at 5:55 PM . R1's physician notified at 6:10 PM . At 6:25 PM, Sheriff's office called facility saying R1 was dropped off at Sheriff's office. Staff picked up R1 at 6:40 PM. R1 appeared in no distress .vital signs taken and head to toe assessment done. R1 had right lateral bruise to ankle. Mild swelling to area noted. R1 complained of pain to right ankle with palpation. Cold packs applied. Physician notified. Unsure at this time how resident left building without alarm sounding. Resident's behavior prior to incident as per usual, confused. Prior to resident's elopement, several attempts made to open outside gate were made, but failed due to AA E being present and redirected R1 away from gate. On 9/1/22 at 11:00 AM, Surveyor spoke to AA E. AA E said she had residents including R1 outside on the patio for an activity from 4:00 PM to 4:55 PM. AA E said she brought all the residents in at 4:55 PM. AA E said she is sure that R1 was not left on the patio. AA E said she propped the keypad alarm door open during the patio activity. AA E said she shut off the chime alarm and put the code in for the keypad alarm. AA E said she was sure the keypad alarm was reset but is not sure she turned the chime alarm back on. On 9/1/22 at 1:30 PM, Surveyor spoke to LPN F. LPN F said she was passing medications during the patio activity. LPN F said when she did not see R1 at the supper table when passing trays, she checked R1's room. LPN F said she asked AA E where R1 was. LPN F said AA E replied she had put R1 at the dining table, then AA E went to the kitchen for the supper trays. LPN F told CNA G to look for R1. LPN F said the alarms were working the entire shift she was there. On 9/1/22 at 1:50 PM, Surveyor spoke to the Sheriff's Department. Deputy K (Deputy) said a citizen dropped R1 off at the Sheriff's Office because R1 was standing in the road. Deputy K said the citizen said she was afraid that R1 would get hit by a car. During the investigation, door alarms were checked by the NHA, ANHA, and SW. The keypad alarms were working, but the chime alarm was in the off position. On 9/1/22 at 2:15 PM, Surveyor spoke to CNA G. CNA G said he had not noticed R1 was missing until LPN F told him to look for her. On 9/1/22, at 2:25 PM during the survey, Surveyor observed R1 sitting at the dining room table, speaking to peers, or working a puzzle. On 9/1/22 at 2:58 PM, Surveyor walked on the unit and heard the alarms sounding. R1 was at the alarmed exit door. LPN I was with R1, redirecting her in a soothing manner. LPN I walked with R1 to TV lounge and sat her in a recliner to watch TV. At 3:14 PM, R1 walked to exit door, walked through the alarmed door with alarms sounding. LPN I sprinted to R1 on the patio (about 60 feet) distance to help R1 back into the building. LPN I went to R1's room and got a puzzle for her to work on with another resident sitting at the table. R1 worked on the puzzle for 30 minutes until Surveyor left the unit. On 9/1/22 at 9:30 AM, Surveyor found an alarmed door showing a green light on the keypad of the alarmed door. Surveyor spoke to MD C (Maintenance Director) and asked what the green light indicated. MD C said the green light on the keypad indicated the alarm on the door was disabled. MD C said he did not know why the alarm on the door was disabled. MD C said there was a specific code used to disable an alarm on a keypad alarmed door. MD C said he was sure he did not go through that door today and the other maintenance person was working in a different building, and they were the only people with an access code to disable alarms. It's important to note that there are four residents in the facility that wander with access to the door with the disabled alarm. On 9/1/22 at 1:00 PM, Surveyor spoke to MD C about the alarmed door in the MCU. MD C said there are two alarms on the doors. The chime alarm goes off when the door is opened and stops alarming when the door is closed. The keypad alarm needs a pass-through code. When the code was applied to the keypad, someone could pass through but not prop the door open. MD C said the door would alarm in 30 seconds when the pass-through code was used. MD C said the keypad alarm resets itself in 10 seconds. Surveyor asked MD C to use the pass-through code and MD C propped the door open for two minutes. The keypad alarm did not sound. MD C said he could not understand why the alarm was not sounding when he propped the door open. Surveyor timed the keypad alarm after the door was closed. The keypad alarm did reset itself in 10 seconds. Surveyor asked MD C how often he checked the alarms for being armed and working. MD C said he checked the alarms every day. Surveyor asked how he checked the alarms.MD C said prior to the elopement, he checked the alarms by observing the light on the keypad. MD C said if the light was red, it meant the door was armed and the alarm was working. MD C said now, after R1 eloped, he checked the MCU door alarm by opening it and making sure it alarmed when opened. MD C said he placed a motion sensor on the outside gate that alarms in the building if someone goes through the outside gate. On 9/1/22 at 5:05 PM, Surveyor spoke to ANHA D and SW H. ANHA D and SW H worked on the investigation of R1's elopement. ANHA D and SW H are also the facilitators of the Person At Risk (PAR) committee for residents with wandering and elopement behaviors. Surveyor asked ANHA D and SW H if they tracked and looked at patterns of behaviors. ANHA D and SW H said no. Surveyor asked what changes have been made to R1's Care Plan to prevent any further elopements. ANHA D and SW H said they updated R1's care plan. Surveyor asked ANHA D and SW H to show Surveyor what changes had been made to R1's care plan. ANHA D and SW H reviewed and compared the original care plan and new care plan for R1. They pointed out the struck-out interventions of do not argue with R1 and do not say you can't, or you have to. Surveyor asked if there were any further changes to prevent R1 from eloping again. ANHA D and SW H said they started an audit of nursing staff checking the alarms on the door in MCU to make sure they are working and checking that R1 has her name bracelet on, and that MD C placed a motion sensor on the outside gate. ANHA D and SW H said those were the changes made to prevent R1 from eloping again. On 9/1/22 at 5:30 PM, Surveyor spoke to NHA A. NHA A said that ANHA D and SW H had worked on the investigation and follow up changes to R1's care plan, and that MD C put a sensor motion alarm on the outside gate. All staff were educated on the door alarms and the elopement and missing person policies. Because R1 was found in the roadway, she was at risk for being hit by a vehicle. According to the article, The Problem of Pedestrian Injuries and Fatalities, Unsafe pedestrian behavior is a major factor in pedestrian injuries and fatalities. In a recent study of 7,000 pedestrian-vehicle crashes in Florida, researchers discovered that pedestrians were at fault in 80 percent of these incidents. Similarly, in a U.K. study, pedestrian behavior accounted for 90 percent of crashes where a vehicle struck a pedestrian. This article notes that, Given a crash, the faster the vehicle the more severe the injury to the pedestrian. For example, a pedestrian hit at 40 miles per hour has an 85 percent chance of getting killed, whereas the likelihood goes down to 45 percent at 30 miles per hour and 5 percent at 20 miles per hour. https://popcenter.asu.edu/content/pedestrian-injuries-fatalities-0 R1 could also have suffered injuries from a fall on the uneven terrain outside. The article, For Elderly, Even Short Falls can be Deadly, notes that even short falls can be harmful, especially to those [AGE] years or older. According to this article, While simple falls, such as slipping while walking off a curb, may seem relatively harmless, they can actually lead to severe injury and death in elderly individuals, according to a new study published in The Journal of Trauma: Injury, Infection, and Critical Care .In contrast to falls from greater heights, ground-level falls - essentially falls from a standing position, with feet touching the ground prior to the fall - have traditionally been considered minor injuries. But, the new study found elderly adults - [AGE] years or older - who experience ground-level falls are much more likely to be severely injured and less likely to survive their injuries compared to adults younger than [AGE] years. Elderly patients are three times as likely to die following a ground-level fall compared to their under-70 counterparts. http://www.urmc.rochester.edu/news/story/index.cfm?id=3020 The facility's failure to ensure R1 had adequate supervision and that door alarms were armed created a reasonable likelihood of serious harm which led to a finding of Immediate Jeopardy. The Immediate Jeopardy was removed on 9/2/22 when the facility began implementing the following: ~All staff were immediately educated on the policies Elopement - Missing Resident Response and Elopement and Wandering Management. They were also reeducated on the alarm system for the door which resident exited from and ensuring a resident sweep/count is completed when residents go outside of the facility and come back in. ~All alarms were recoded to ensure that staff do not know the code to disengage alarms. ~All residents who are at risk for wandering/elopement were audited, reassessed as required, and care plans were updated for appropriateness. ~Affected resident's care plan was updated to include offer increased structured activities to resident that are specific to her, daily itinerary to help deter from exit seeking, i.e., ice cream social, movie in sensory room, puzzle, sorting activities, etc. ~Increased staffing of MCU to include daily manager rounds as well as weekend manager rounds. ~Resident to be in line of sight of staff during awake hours. ~Daily MCU door check audit to include ensuring alarms are engaged to alarm properly by maintenance director or designee to be completed and brought to ID Team each day. ~Random spot checks with staff on elopement attempts to help monitor timeliness of response to alarms. This will be done daily x 2 weeks, and then 3x weekly for 4 weeks by manager rounds. ~Increased rounding daily on memory care unit x4 weeks by all management staff to ensure residents are engaged and not exit-seeking and there is sufficient staff. ~Wandering and elopement assessments and care plans will be reevaluated weekly ongoing through facility care plan meetings and facility person-at-risk meetings over the next 12 weeks and changes made as appropriate.

Based on observation, interview and record review the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety to prevent foodborne illness for 1 of 12 sampled resident (R28) and 1 of 1 supplemental residents (R13) who were served non-pasteurized eggs with runny yolks that were not set and completely firm. Failure to ensure that eggs served were pasteurized or fully cooked placed these residents at risk for becoming infected by Salmonella and created a finding of Immediate Jeopardy (IJ) beginning on 2/15/22. The NHA A (Nursing Home Administrator) was informed of the Immediate Jeopardy on 2/15/22 at 11:00 AM. The Immediate Jeopardy was removed on 2/16/22, however the deficient practice continues at a scope/severity of F (potential for harm/widespread) as the facility implements its removal plan. Findings include: According to the 2017 FDA Food Code: 3-302.13 Pasteurized Eggs, Substitute for Raw Shell Eggs for Certain Recipes. Raw or undercooked eggs that are used in certain dressings or sauces are particularly hazardous because the virulent organism Salmonella Enteritidis may be present in raw shell eggs. Pasteurized eggs provide an egg product that is free of pathogens and is a ready-to-eat food. The pasteurized product should be substituted in a recipe that requires raw or undercooked eggs. Highly susceptible population means PERSONS who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; preschool age children, or older adults; and (2) Obtaining FOOD at a facility that provides services such as custodial care, health care, or assisted living, such as a child or adult day care center, kidney [CONDITION(S)] center, hospital or nursing home, or nutritional or socialization services such as a senior center. 3-801.11 Pasteurized Foods, Prohibited Re-Service, and Prohibited Food. In a FOOD ESTABLISHMENT that serves a HIGHLY SUSCEPTIBLE POPULATION: (B) Pasteurized EGGS or EGG PRODUCTS shall be substituted for raw EGGS in the preparation of . (2) A partially cooked animal FOOD such as lightly cooked FISH, rare MEAT, soft-cooked EGGS that are made from EGGS, and meringue; The facility does not have a policy regarding the use of unpasteurized eggs or the safe handling and/or cooking of shell eggs. On 2/14/22 at 10:25 AM during the initial tour of the kitchen Surveyor observed shelled eggs in the facility's walk in refrigerator, in a box. Surveyor observed that there was no P mark on the eggs, which would indicate the eggs were pasteurized. Surveyor observed no indication on the gray crates or the box the eggs were pasteurized. Cook O informed the Surveyor the facility buys pasteurized eggs and non-pasteurized eggs. Cook O indicated she tries to use them equally. Cook O stated, Today I used pasteurized eggs and tomorrow I will use the non- pasteurized eggs. On 2/15/22 between 7:15 AM - 9:00 AM Surveyor observed a gray crate on the counter with 8 shelled eggs. Cook O indicated she is using non-pasteurized eggs today and serves over easy eggs/sunny side up eggs to two residents daily. Surveyor observed Cook O crack eggs into a frying pan and cook eggs over easy. Surveyor observed R13 and R28 eating over easy eggs with a runny yolk. R13 and R28 cut into egg and yellow yoke ran onto plate. Surveyor observed eggs still sitting on counter and asked Cook O to temp one of the eggs. The temperature was 60 degrees. Cook O stated, I think eggs can stay out at room temperature. Surveyor asked Cook O if she received any training on pasteurized versus non-pasteurized eggs. Cook O indicated she had not. On 2/15/22 at 9:15 AM Surveyor informed NHA A and Corporate Clinical Services Assistant G of the concern that eggs were being used to provide over easy eggs to residents that did not have indications that they were pasteurized. Corporate Clinical Services Assistant G informed the kitchen to stop using the eggs at that time. Surveyor asked if the facility has a policy and procedure related to undercooked eggs/use of pasteurized eggs. NHA A informed Surveyor it is the facility's practice to use pasteurized eggs for eggs that are not cooked hard. NHA A indicated she was not sure if it was written in policy, but that it is the procedure the facility follows. On 2/15/22 at 9:30 AM Corporate Clinical Services Assistant G provided the Surveyor with the order details for Martin Brothers Food Service with a submission dates of 1/31/22 and a delivery dates of 2/10/22. The surveyor noted an order for item number 8 with a description of eggs pasteurized medium shell and an order for item number 0 with a description of eggs large grade A. The serving of unpasteurized eggs that were not fully cooked created the potential for residents to contact Salmonella. This created a finding of Immediate Jeopardy. The Immediate Jeopardy was removed on 2/16/22 when the facility began implementing the following: All residents that were served the unpasteurized eggs will be monitored for signs and symptoms of food borne illness, including: fever, abdominal pain, nausea, vomiting; every shift for 72 hours then every day for an additional 48 hours. Any signs or symptoms of illness will be reported immediately to resident's Medical Doctor. All dietary employees immediately trained on correct/complete preparation of unpasteurized eggs. Employees educated on difference between use of pasteurized and unpasteurized eggs. All unpasteurized eggs were discarded in facility dumpster. Facility will only purchase pasteurized eggs in the future. NHA A to verify purchases of pasteurized eggs through food vendor. Food vendor to notify NHA A if an egg substitution has to be made due to unavailability of product. Food vendor (Martin [NAME]) locked out unpasteurized eggs from order guide for facility. NHA A will observe tray line twice weekly to ensure pasteurized eggs are being used for one month and then weekly for 2 additional months. NHA A will observe food delivery every week for 3 months to ensure pasteurized eggs are delivered. NHA A will notify all cooks to ensure only fully cooked eggs are served, if unpasteurized eggs are served (if an egg substitution had to be made by vendor due to unavailability of product. The deficient practice continues at a severity/scope of G (potential for harm/widespread) as evidenced by: STOVEHOOD On 2/14/22 at 10:25 AM during initial tour of the kitchen, Surveyor observed hair-like dust in the stove hood unit. The dust was on the arm and spout of the faucet, on the metal piping, on the filter/vents, and along the front edges that were up inside stove hood. Cook O indicated the dust could dislodge into the food being prepared underneath it, especially with the rising steam. Cook O showed Surveyor steam rising from the pot of beets cooking on the burner. On 2/17/22 at 2:41 Surveyor, NHA A, Corporate Consultant/ Registered Dietician M, and Corporate Clinical Services Assistant G observed the stove hood to still have hair-like dust hanging from the spout and arm of the faucet, along the piping, and on the vent/filters. Corporate Clinical Services Assistant and Corporate Consultant/Registered Dietician M indicated the facility's Maintenance Man would be addressing this immediately. SCOOPS On 2/15/22 at 8:25 AM Surveyor observed 3 scoops to be lying in contact with dry cereal, inside of 3 storage containers. Cook O indicated the scoops should not be left inside of the container, but she was not sure why. Cross Reference: F 801, F802, F803 and F804

Based on interview and record review the facility did not ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcer interventions for 1 (R7) of 3 sampled residents reviewed for pressure ulcers of a total sample of 16. R7 developed a stage 3 pressure injury (full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through, underlying fascia) to her gluteal cleft due to her cushion being in disrepair and the staff were unaware. Evidenced by: The Facility's Policy and Procedure entitled Skin Care Management with a revision date of 8/21 documents, in part: .5. Skin is monitored routinely during care giving .Skin integrity will be monitored at least weekly on the resident's bath day for all residents that are identified at risk . According to Hand Check Method: Is It an Effective Method to Monitor for Bottoming Out? A National Pressure Ulcer Advisory Position Statement. Wound Care Advisor, vol. 4, no. 5, R7 is a long term resident of the facility. R7 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's most recent MDS (Minimum Data Set) dated 11/10/21 documents a BIMS (Brief Interview of Mental Status) score of 13, which indicates R7 is cognitively intact. R7's admission skin assessment from 6/20 documents that R7 had a stage 2 pressure injury to her gluteal cleft upon admission to the facility, therefore, the facility was aware that this area was at risk. R7's Braden scale (is an evidenced-based tool that predicts the risk for developing a pressure injury), prior to development of this stage 3 wound, was 18 (mild risk) on 10/21/21. R7's care plan documents the following, in part: PROBLEM: Overweight, presence of PI (pressure injury), RELATED TO: physical inactivity, skin breakdown, MANIFESTED BY: BMI (Body Mass Index) > (greater than) 25, but < (less than) 30, stage III PI on coccyx ., this care plan is dated 1/13/22 and PROBLEM: Tissue integrity impairment (Stage 3 PI to Intergluteal Crease), RELATED TO: History of Stage II on admission to gluteal cleft; MASD (moisture associated skin damage) Coccyx/Gluteus, MANIFESTED BY: Incontinence, Pressure ., this care plan is dated 1/20/22. R7's CNA (Certified Nursing Assistant) care plan documents the following, in part: .wheelchair with Equalizer Cushion for pressure reduction .Low Bed with pressure reduction mattress . calazinc cream to coccyx/gluteal crease BID (twice per day) and PRN (as needed) . R7's last documented shower and skin assessment was on 1/3/22 with no skin concerns present. R7's cushion, previous to stage 3 PI development, had the following manufacturer's recommendations- seat cushion gel-u-seat lite, designed to redistribute pressure to assist in the prevention of pressure ulcers while providing patient comfort. This cushion was noted to be in disrepair upon evaluation of the device on 1/18/22-1/19/22. It was replaced with the following cushion; Equalizer cushion that has the following manufacturer's recommendations- Braden < 12, sits for long periods, insensate (lacking physical sensation), existing ulcer on ischium or coccyx and/or history of sitting ulcer. R7's mattress, previous to stage 3 PI development, is unknown. R7's received the GEO-Mattress UltraMax after stage 3 PI development and it has the following manufacturer's recommendations- prevention of stage 1-4 pressure injuries, early intervention for multiple stage -2 and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility's root cause analysis of R7's PI development documents the following: 1 newly identified Stage 3 Pressure Injury 1/12/22 .newly acquired- In house Acquired .Wound nurse completing root cause analysis, resident noted to need new w/c (wheel chair) cushion and bed mattress, R7 will be placed on individualized appropriate supportive device to maintain skin integrity, all residents with anti-rollbacks to have chairs and cushions audited 1/19/22 with IDT (Interdisciplinary Team) discussion on plan to follow up to ensure all issues identified and acted upon . target date 1/20/22. R7 had anti-roll back device applied to wheelchair on 10/19/21 as a fall intervention. R7's Nurses Notes document the following: 1/12/22 at 10:26 PM- observed open area to coccyx, area cleansed, hydrogel applied and [MEDICATION(S)] dressing in place 1/13/22 at 11:33 AM- Late entry for: 1/12/22 WEEKLY SKIN ASSESSMENT: Wound nurse updated on new area noted on resident's coccyx. Assessment completed, resident noted to have Stage 3 PI noted to intergluteal crease measuring 2.0x0.5x0.3, protocol implemented, cleanse with wound cleanser, barrier wipe to surrounding tissue, amorphous to wound bed, cover with bordered gauze daily. Will continue to monitor. See Skin Care Flow Sheets. 1/19/22 at 6:13 PM- Late entry for: 1/18/22 WEEKLY SKIN ASSESSMENT: Weekly wound assessment completed, measurement obtained. PI-3 to Intergluteal Crease has beefy red base, edges well defined, no [CONDITION(S)] noted, Dr .rounded and assessed wound, agreed with current treatment protocol, POA (Power of Attorney) updated. Root cause completed, current w/c cushion not appropriate, anti-rollback device was felt through cushion, cushion changed to Equalizer, verified mattress appropriate. Will continue to monitor. See Skin Care Flow Sheet. 1/25/22 at 11:53 PM- WEEKLY SKIN ASSESSMENT: Weekly wound assessment completed, measurement obtained. PI-3 to intergluteal crease continues to have beefy red base, edges well defined, no [CONDITION(S)] noted, Equalizer cushion comfortable per resident. Will continue to monitor. See Skin Care Flow Sheets. 1/29/22 at 9:51 PM- Tx (treatment) to OA (open area) on coccyx as ordered. Wound is stable in size, no odor or drainage from site. Res (resident) denies pain, small amt (amount) yellow slough on wound base. 2/2/22 at 9:34 PM- Late entry for 2/1/22 WEEKLY SKIN ASSESSMENT: Wound nurse completed weekly assessment, measurement obtained. PI-3 to intergluteal crease improving, deep pink base, edges well defined, no [CONDITION(S)] noted, no drainage noted. Will continue to monitor. See Skin Care Flow Sheets. 2/9/22 at 5:33 PM- FAX SENT TO: Dr .REGARDING: Wound nurse requesting a change in treatment order to Coccyx Pressure Injury. 2/6/22 at 5:40 PM- Late entry for 2/8/22 WEEKLY SKIN ASSESSMENT: Weekly wound assessment completed by wound nurse. Coccyx Pressure Injury is unstageable, slough to wound base, no [CONDITION(S)] noted, no drainage noted, denies any pain or discomfort, fax sent to Dr .requesting order change. Will continue to monitor. See Skin Care Flow Sheets. It is important to note that the amount of each tissue type in R7's wound is not documented in Nurses Notes or on the Skin Care Flow Sheets; a vital part of wound care documentation is to know what percentage of each tissue type are present in the wound, even if viewed as an approximated percent. R7's Skin Care Flow Sheets document the following: (Headings to top of sheet include: Date/Wound type and category/Dimensions/Wound Base/Exudate, Type and Amount/Odor/Presence of Pain/Healing Progress (Wound base, Surrounding Tissue and Wound Edge Margins)/Treatment/Initials) 1/12/22- PI- 3 coccyx, 2.0x0.5x0.3, yellow slough, red pink epithelial beefy base macerated edges, no exudate, no odor, no pain, new- slough noted no [CONDITION(S)], treatment- amorphous/bordered foam 1/18/22- PI- 3 coccyx, 2.2x0.5x0.5, yellow slough, red pink epithelial beefy base macerated edges, no exudate, no odor, no pain, red, beefy base, edges defined, macerated, deeper at center of wound, treatment- amorphous/bordered foam 1/25/22- PI- 3 coccyx, 2.2x0.5x0.5, yellow slough, red pink epithelial beefy base macerated edges, no exudate, no odor, no pain, same as previous week, treatment- amorphous/bordered foam 2/1/22- PI- 3 coccyx, 1.5x0.5x0.5, deep pink macerated edges, no exudate, no odor, no pain, improving, no [CONDITION(S)], edges defined, treatment- amorphous/bordered foam 2/8/22- PI-U (unstageable) coccyx, 1.8x0.5x0.5, slough, no exudate, no odor, denies, slough, no [CONDITION(S)], edges defined, cleanse, skin prep peri-wound, medi-honey, island dressing It is important to note that the amount of each tissue type in R7's wound is not documented in Nurses Notes or on the Skin Care Flow Sheets; a vital part of wound care documentation is to know what percentage of each tissue type are present in the wound, even if viewed as an approximated percent. Observation on 2/15/22 at 8:23 AM: R7 noted to be in bed, lying on back, mattress had fitted sheet, draw sheet, and cloth soaker pad on it, no air mattress on bed; cushion for wheel chair noted to be on bedside table. On 2/15/22 at 12:42 PM, Surveyor interviewed R7. R7 noted to be sitting up at bedside eating lunch. Surveyor asked R7 if she had any pain to the wound on her bottom, R7 said she has no pain. Surveyor asked R7 if the staff assess the wound, R7 replied they are looking at it every day and put a new bandage on. On 2/16/22 at 11:15 AM, Surveyor interviewed RN C (Registered Nurse) who is the Facility's current Wound Nurse. Surveyor asked RN C if she was wound care certified, RN C said she was not wound certified but does have two wound care certified nurses (CQA F (Corporate Quality Assurance) and CC M (Corporate Consultant)) as resources. Surveyor asked RN C what R7's current measurement from this week was, RN C stated it was measured 2/15/22, 1.3x0.3x1.1, deepest part in center of wound. RN C went on to explain that R7 has a deep gluteal cleft, indicating that just upon standing you would not see this wound. Surveyor asked RN C what unit of measure is used to measure wounds, RN C replied always in cm (centimeters). Surveyor asked RN C what percentage of each tissue type are present in the wound, RN C stated light yellow slough to center 25%, granulation tissue to edges 75%, and maceration to edges of the wound. Surveyor asked RN C what is being applied to the macerated wound edges, RN C said just skin barrier. Surveyor asked RN C if the percentage of tissue type was documented anywhere weekly, RN C said no. Surveyor asked RN C what the Facility determined the root cause to be for R7 developing this wound; RN C stated the anti-rollback device was felt through R7's wheel chair cushion, causing pressure to this area. Surveyor asked RN C when the anti-roll back device was placed on R7's wheel chair, RN C said she didn't know exactly when but that maintenance applies them and he said that they've been on the chair awhile, not new. It is important to note that a vital part of wound care documentation is to know what percentage of each tissue type are present in the wound, even if viewed as an approximated percent. Listening Observation on 2/16/22 at 11:18 AM. R7 declined Surveyor to view wound and treatment application but allowed Surveyor to listen to RN C as wound care was completed. RN C verbalized the following while conducting wound care: R7 turned to right side, cleansed with wound cleanser, dried with gauze, medi-honey applied to wound bed, skin prep applied to peri-wound, and island dressing (bordered foam) to cover. RN C asked R7 if she had any pain, R7 stated no, no pain. On 2/16/22 at 1:26 PM, Surveyor interviewed CNA I. Surveyor asked CNA I if she has had any education about pressure injuries, CNA I said she's pretty new (hire date of 1/13/22) has not had education upon hire regarding pressure injuries. It is important to note that R7's stage 3 pressure injury was discovered 1/12/22. On 2/16/22 at 1:33 PM, Surveyor interviewed RN J. Surveyor asked RN J if she knew how R7's wound was discovered, RN J replied it was found during cares. Surveyor asked RN J if R7 is agreeable to cares, RN J said R7 allows cares pretty routinely. Surveyor asked RN J if she has had any education about pressure injuries, RN J said they were given a PI worksheet in the summer of 2021, but nothing since then. On 2/16/22 at 1:35 PM, Surveyor interviewed CNA D. Surveyor asked CNA D if R7 is agreeable to cares, CNA D said R7 often declines cares, she doesn't want to be here and is very particular about who does her cares. Surveyor asked CNA D if she could explain how peri-care is provided to R7, CNA D explained R7 stands for peri-care, her legs are bowed which makes it difficult to get in between but if you ask her, she will spread her legs apart as needed. Surveyor asked CNA D if the depth of her gluteal cleft made it difficult to see the wound, CNA D said yes. Surveyor asked CNA D if she has had any education about pressure injuries, CNA D said she thought about 5 weeks ago, she was given a pamphlet to read with signature regarding pressure injuries. On 2/16/22 at 1:43 PM, Surveyor interviewed CNA K. Surveyor asked CNA K if R7 is agreeable to cares, CNA K said she is resistive to cares from men, so I don't provide cares to her. Surveyor asked CNA K if he has had any education about pressure injuries since R7 developed her wound, CNA K stated I didn't know she had a wound, yes I think so, had to sign a slip. Surveyor asked CNA K if the education was recent, CNA K said he couldn't be sure when but recently. On 2/17/22 at 9:07 AM, Surveyor interviewed CQA F (Corporate Quality Assurance). Surveyor asked CQA F if the staff were provided with any education after R7 developed the wound, CQA F stated no, no education regarding skin since R7 developed wound. Surveyor asked CQA F if there had been any skin audits of documentation since R7 developed the wound, CQA F said no skin audits besides RN C completing wound rounds weekly, but a cushion audit was completed 1/18/22-1/19/22 which is how they found R7's cushion to be bottomed out and could feel the anti-roll back bar through the cushion in her wheel chair. CQA F said new cushions were ordered 1/24/22 for all that required them and placed as soon as they were delivered. On 2/17/22 at 2:09 PM, Surveyor interviewed CC M (Corporate Consultant). Surveyor asked CC M if she is wound care certified, CC M said yes. Surveyor asked CC M if wound documentation should include the percentage of each type of tissue present in a wound, CC M said yes. Surveyor asked CC M if she would expect for a wound to be discovered when reddened vs (versus) at a stage 3; CC M replied typically the CNA's are finding skin alterations and reporting them right away, R7 is a bit rotund and wound is in a deep crevice. Surveyor asked CC M if she was aware that R7 had a wound to this same area upon admission to the facility, CC M said yes, this similar area of breakdown, she did have upon admission. On 2/17/22 at 2:45 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if she was aware of how staff are completing peri-care for R7, DON B explained that she has provided R7 peri-care in the evening on occasion. Surveyor asked DON B to elaborate, DON B explained that R7 was in bed, brief was removed, she was wiped clean, and new brief applied. Surveyor asked DON B if she would have been able to see this wound the way she completed peri-care to R7, DON B said only if her buttocks was held up so the inner cleft was visible. Surveyor asked DON B if she feels that providing R7's peri-care while standing would allow the CNA's to see into her gluteal cleft, DON B said no, not unless you had assistance on each side. Surveyor asked DON B if she feels that providing R7 with peri-care while standing could have contributed to not seeing this wound sooner, DON B said yes. Surveyor asked DON B if she would expect wound documentation to include the percentage of each type of tissue present in a wound; DON B stated yes, definitely. Surveyor asked DON B if she would expect for a wound to be discovered when reddened vs at a stage 3; DON B replied yes, usually the CNA's are very good about reporting even tiny red spots. Surveyor asked DON B if there had been any education on pressure injuries or cushion function such as a assessing/monitoring the effectiveness of seat cushions per manufacturer guidleines, DON B stated not that I'm aware of. On 2/17/22 at 2:59 PM, Surveyor interviewed CQA F. Surveyor asked CQA F if she was aware that R7 is typically receiving peri-care while standing, CQA F said yes, in bathroom generally. Surveyor asked CQA F if she feels that providing R7 with peri-care while standing could have contributed to not seeing this wound sooner, CQA F stated no, I'd say her history of wound to that area and need to clean really well to be able to see it contributed. Surveyor asked CQA F if there had been any education on pressure injuries or cushion function such as a assessing/monitoring for botoming out since R7 developed this wound, CQA F said the Maintenance Director would have cushions added to his bed audit and Wound Nurse would also audit during wound rounds. It is important to note that education on cushion function such as a assessing/monitoring for cushion function such as a assessing/monitoring the effectiveness of seat cushions per manufacturer guidleines, which was the root cause of R7's PI development, was not given to the front line staff (CNA's and Nurses) that are working with R7 daily, this education is essential to prevent reoccurrence as they would be the first staff to alert someone if there was a concern with the bottoming out or other cushion related concerns.

Based on observation, interview and record review the facility did not ensure that residents receive care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers for 2 of 4 residents (R3 and R41) reviewed for pressure injuries out of a total sample of 15 and 1 of 4 residents (R6) observed for proper treatment application out of a total sample of 15. R3 developed an unstageable wound to her left heel after she sustained a fracture at the facility. R41 developed a stage II wound to coccyx, a stage II wound to left heel and a DTI (Deep Tissue Injury) to right heel during a multi-faceted change of condition at the facility. R6's wound treatment had a breach in infection control practice during observation. This is evidenced by: The Facility's Policy and Procedure entitled Skin Care Management, revised 10/20, documents in part: It is the policy of this nursing home to provide skin care to residents that includes assessment, prevention of skin breakdown and management of pressure injury and other skin integrity concerns .2. The Skin and Body Assessment Form is to be completed .if there is a significant change in the resident's condition, acuity or alterations to skin .3. The Braden Scale pressure injury risk assessment will be completed .if there is a significant change in the resident's condition, acuity or alterations to their skin .5. Skin is monitored routinely during care giving, and problems identified will be documented on the Skin and Body Assessment Form .9. The QAPI (Quality Assurance Process Improvement) Committee will analyze trends in facility skin alterations for quality improvement .Any facility-acquired pressure injuries .require a comprehensive root cause analysis and correction through a performance improvement plan (PIP) by the QAPI committee . Manufacturer's recommendations for the Geo-Mattress, undated, documents in part: .Use for Prevention when- Moderate-High Risk (e.g., Braden 12-18), Decreased mobility, Repositions frequently by self or caregiver, Decreased skin integrity; Use of Treatment when- Cause of ulcer is not pressure (e.g., nutrition, continence, circulation, etc), Causes of ulcer are being addressed, Patient can be positioned off of the ulcer in at least 2 different positions . It is important to note that both R3 and R41 are utilizing this mattress. Manufacturer's recommendations for the Truvue Heel Protector, dated 2020, documents in part: Indications for Use- Prevention and management of pressure injury of the heel .Set-Up .Step 5: Verifying Offloading- Place your hand under the heel to ensure that the heel is offloaded . Example 1 R3 is a long term resident of the facility. R3 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/12/21 at 11:36 AM, Surveyor interviewed FM P (Family Member). Surveyor asked FM P if she had any concerns with R3's care, FM P said no after her fall when she broke her left leg in three places, she developed a wound on her heel but they are treating that. Surveyor asked FM P what leg was broken, FM P said R3's left leg. Surveyor asked FM P what heel has the wound on it. FM P said her left. Surveyor asked FM P if the staff knew how she developed that wound on her heel, FM P stated I suppose from laying in bed all the time. R3 sustained on fall on 3/18/21. It was decided by R3 and FM P that they did not want to pursue surgery but instead remain in the facility and maintain comfort. The facility failed to implement interventions to prevent R3 from developing a PI (pressure injury) with her new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R3's care plan for skin dated 9/18/19 documents in part: .Problem: 6. Moderate risk for Impairment of skin integrity .Problem: broken left lower leg 3/22/21, PI unstageable left heel 7/2/21 . The following approaches were added to the care plan 7/2/21: .bed cradle to foot of bed, heel lift boots to bilateral feet at all times, elevate heels as tolerated, and [MEDICATION(S)] to left heel BID . R3's CNA care card documents, in part: .heel lift boots to bilateral feet at all times, assist to bed in between meals and assure left leg remains elevated while in bed or recliner . R3's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's TAR (treatment administration record) does not include any documentation of checking heels from date R3 fractured LLE (left lower extremity) on 3/18/21 or after. R3's TAR does include the following with an entry date of 3/19/21: Circulatory Treatment: CMST (circulation, motion, sensation, temperature) check(s) to left lower extremity every shift . It is important to note this treatment was signed off every shift from 3/19/21 through the date of 4/25/21 when the PI at an unstageable level was discovered. R3's Braden assessments were scored as follows: 2/16/21= 16 (before the fracture), 3/25/21= 15 (after the fracture), 3/30/21= 15, 4/5/21= 15, 4/7/21= 15, 4/14/21= 15, 4/21/21= 15 (prior to PI discovery), and 4/26/21= 14 (date PI 1st assessed). Braden Risk Assessment is scored from 6-23, the lower the number the more at risk. A score of 15-16 indicates that R3 is at mild risk for pressure injury. A score of 14 indicates that R3 is at moderate risk for pressure injury. R3's Nurse's Notes document the following: 3/18/21- .she does have fractures in three places, she does not want any treatment and neither does FM P, temporary cast will be put on, if leg swells you can un-ACE it, she will be coming back with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 3/19/21- Resident has LL (left leg) fracture .Pillow placed under left knee area . 4/26/21- PI unstageable left heel cleanse, pat dry, apply [MEDICATION(S)] BID(Twice daily). R3's Skin Care Flow Sheet dated 3/18/21 for Fracture of Left Leg documents: .Facility acquired fracture, new on 3/18/21, ER (emergency room ) eval (evaluation)-Fracture- soft splint at all times . First assessment is dated 3/23/21. R3's Skin Care Flow Sheet dated 4/25/21 for PI unstageable blood fluid filled left heel documents: Facility acquired, date of origin: 4/25/21, first documented assessment is dated 4/26/21: PI unstageable, 4.3 cm (centimeters) X (by) 5.7 cm, fluid filled (red), new MD (Medical Doctor) updated, tissue tolerance, heel lift boots at all times, [MEDICATION(S)] BID . On 5/4/21 it is noted that the wound is not flat/red and by 5/18/21 it is noted that the wound is Flat/dry Red. On 7/13/21 at 8:12 AM, Surveyor observed R3's wound treatment to left heel. LPN C (Licensed Practical Nurse, Wound Nurse) completed treatment with assistance from CNA F (Certified Nursing Assistant). LPN C stated R3 has those (pointed to them) boots on in bed, but were removed to complete treatment. LPN C showed Surveyor R3's right heel, had some redness that was blanchable, but nothing now. LPN C showed Surveyor R3's left heel, hard brown intact eschar with lifting edges, wound measured 1.9 cm X 2.1 cm. LPN C said R3's wound started as blood filled blister, R3 does not have any pain. LPN C completed [MEDICATION(S)] treatment as ordered. On 7/13/21 at 8:25 AM, Surveyor interviewed LPN C. Surveyor asked LPN C what interventions does R3 have in place for her heel wound, LPN C stated weekly wound round, heel boots at all times, heels floated in bed, and foot cradle in bed. Surveyor asked LPN C if the facility concluded what the root cause of R3's development of PI was. LPN C said R3 was digging her heels into bed, so we started boots right away. On 7/14/21 at 7:49 AM, Surveyor observed R3 in bed on back with pillow under her knees; boots were on but heels were resting on bed, foot cradle was not on bed. On 7/14/21 at 10:20 AM, Surveyor interviewed CNA F. Surveyor asked CNA F when R3 had the heel boots started. CNA F stated I'm not sure when the boots got put into place. On 7/14/21 at 2:37 PM, Surveyor interviewed RN E (Registered Nurse). Surveyor asked RN E when the heel boots were implemented for R3, RN E said boots initiated after the wound developed. Surveyor asked RN E what interventions were put into place after R3 fractured her leg and before the PI developed. RN E replied floating heels, checking heels every shift, and pillow under calf. Surveyor asked RN E to describe what type of cast/soft splint R3 had on her left leg after she fell and fractured. RN E explained it was a soft velcro splint that was to be on at all times, it went from thigh to ankle, and bare foot was not enclosed in splint. When Surveyor asked RN E was R3's heel exposed the entire time she had the splint on, RN E said yes. On 7/15/21 at 1:29 PM, Surveyor interviewed LPN C. Surveyor asked LPN C how to identify when R3's heel boots or floating heels was implemented. LPN C said date on the care plan is when intervention was initiated. Surveyor asked LPN C if there is documentation of RCA (root cause analysis) for R41's development of his wounds. LPN C stated no, we had a verbal discussion and review of room etc, but there is no documentation. On 7/15/21 at 2:56 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if there was any documentation of checking R3's heels. DON B said she would have to look. Surveyor asked DON B where would documentation of floating heels be located. DON B replied in the TAR. Surveyor asked DON B if there is documentation of RCA (root cause analysis) for R3's development of his wounds. DON B stated LPN C handles all the wound stuff, we discuss wounds every day, she completes the skin sheets every week, the CNA's report skin concerns right away, the nurses check with the CNA's, and we follow our facility policy. Surveyor asked DON B what was the root cause for R3's PI developing. DON B stated root cause was her fractured leg. It is important to note that no additional information was given to the Surveyor regarding documentation of checking heels. It is also important to note that the Facility is not following their facility policy in regard to ensuring each facility acquired wound has a RCA completed. Example 2 R41 is a long term resident of the facility. R41 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R41's care plan for skin dated 4/2/21 documents in part: .Problem: Impairment of skin integrity .MASD (Moisture-Associated Skin Damage)/Shearing Stage II- Coccyx/Gluteus 3-24-21 .DTI Right Heel; PI Stage II Left Heel .Approach .Assess skin status, Assess nutrition status Keep MD (Medical Doctor) informed .Geo mattress on bed .Geo PRT cushion .Offload heels while in bed. Document every shift on acceptance and refusals of ADL's (Activities of Daily Living), medications, treatments, offloading of heels ect . R41's CNA care card documents, in part: .Off-load heels with pillow at all times while in bed . R41's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R41's TAR for the above two orders begins 6/15/21. Since 6/15/21, the TAR is initialed every shift. For the order that reads Document every shift on acceptance and refusals . It should be noted the facility initialed this on the TAR each shift however there is no way to determine if the initials indicate R41 accepted or refused the treatment. R41's Braden assessments were scored as follows: 3/9/21= 14, 3/25/21= 17, 4/1/21= 16 and 4/7/21= 16. Braden Risk Assessment is scored from 6-23, the lower the number the more at risk. A score of 16-17 indicates that R41 is at mild risk for pressure injury. A score of 14 indicates that R41 is at moderate risk for pressure injury. R41's Nurses' Notes document the following: 4/2/21 at 11:18 AM .11) Pressure Injury II Fluid Filled Blister- Left Heel- Cleanse, pat dry, apply [MEDICATION(S)] to wound bed, cover with soft foam dressing and wrap with kerlix daily. 12) Deep Tissue Injury- Right Heel- Cleanse, pat dry, apply [MEDICATION(S)] to wound bed, cover with soft foam dressing and wrap with kerlix daily. 13) NO shoes to be worn to bilateral feet . 4/2/21 at 1:55 PM Treatment held d/t (due to) resident refused There is no indication as to what treatment this is referring to. 4/6/21 at 2:38 PM Treatment held resident refused & also is on isolation and cannot leave room at present There is no indication as to what treatment this is referring to. 4/7/21 at 1:13 PM Fax sent to Dr regarding promoting wound healing, new orders for Pro-stat 30 mL (milliliters) BID (twice per day) 4/9/21 at 5:43 PM Treatment held d/t (due to) resident refused There is no indication as to what treatment this is referring to. 4/11/21 at 9:13 PM Treatment held d/t (due to) resident refused There is no indication as to what treatment this is referring to. 4/12/21 at 1:13 AM PRN (as needed) Tylenol given for pain to both heels, rated 7, Follow up at 5:21 AM effective resting 4/14/21 at 9:14 AM (late entry for 4/13/21) new orders 1) Skin Treatment: Deep Tissue Injury-Right Heel- Cleanse, pat dry, apply [MEDICATION(S)] to wound bed, cover with ABD (abdominal) Pad and wrap with kerlix daily. 2) Skin Treatment: Pressure Injury Stage II-Fluid Filled Blister-Left Heel- Cleanse, pat dry, apply [MEDICATION(S)] to wound bed, cover with ABD Pad and [NAME] with kerlix daily. 4/16/21 at 2:40 PM Treatment held d/t (due to) resident refused There is no indication as to what treatment this is referring to. 4/27/21 at 10:32 AM Treatment held resident refused There is no indication as to what treatment this is referring to. 4/29/21 at 1:18 AM Resident refusing to reposition despite being re-approached several times and education from RN (Registered Nurse) about importance of repositioning. Redness to R hip remains blanchable. The Facility did not complete a risk versus benefits for R41 or R41's responsible party in regard to skin interventions. Hospital records date 3/31/21 through 4/1/21: .Pressure Ulcers-Buttocks: Patient was noted upon arrival to have a stage I pressure ulcer to his coccyx which is now blanchable and intact, [MEDICATION(S)] should be used regularly as a skin barrier protectant as he is incontinent especially with his C. difficile diagnosis. Regular repositioning is essential. Left Heel: There is a noted stage II pressure ulcer on admission to the patient's left heel. It is a clear blister that is intact at this time. It measures 6 cm X 6 cm. and encompasses most of his posterior heel. Dressing change orders are to include #1. Offloading heels at all times while in bed or in chair. #2. Daily, until the blister has resolved, apply [MEDICATION(S)] to the heel followed by a heel cup and dry gauze bandage for securement .Right Foot: There is noted to be a deep tissue injury on the posterior aspect of the right heel that measures approximately 2 cm X 2 cm .Dressing instructions for the nursing home consist of offloading heel at all time, [MEDICATION(S)] swab to deep tissue injury daily .Concerns for PCP (Primary Care Physician) to follow up on: .and closer monitoring for skin breakdown as patient is developing multiple pressure ulcers. Consideration for new mattress or other devices to help with offloading should be evaluated . R41's Skin Care Flow Sheet for Stage II-MASD/Shearing to coccyx/gluteus has a date of origin as 3/25/21. R41's Skin Care Flow Sheet for DTI to right heel and Stage II to left heel have a date of origin as 4/1/21. It is important to note that this is the date that R41 returned from the hospital, however, per the hospital record, these wounds were present on admission to the hospital on 3/30/21. On 7/13/21 at 2:22 PM, Surveyor observed R41's wound treatment to heels. LPN C showed Surveyor that left heel is blanchable and intact. Right heel wound is noted to be on the outer aspect of right heel, wound bed is brown hard eschar with edges noted to be lifting up and curled inward, R41 complained it hurts, when LPN C cleansed. LPN C stopped treatment to get pain medication. Later, once pain medication had time to work LPN C went back to measure 0.7 cm X 0.5 cm and completed treatment. On 7/14/21 at 7:51 AM, Surveyor observed R41 in bed, foot cradle on, fuzzy socks on feet, and heels not floated. On 7/14/21 at 2:37 PM, Surveyor interviewed RN E. Surveyor asked RN E how she thought R41 developed the wound to his right heel, RN E stated he lays on that side and isn't always cooperative with floating heels, and won't stay turned off that side. On 7/15/21 at 10:09 AM, Surveyor interviewed RN D. Surveyor asked RN D what interventions are in place for R41's heel wound, RN D replied heel positioning in bed with use of pillows but he kicks them out. Surveyor asked RN D if they document refusals of care, RN D said yes they are documented in our TAR. On 7/15/21 at 10:19 AM, Surveyor interviewed CNA G. Surveyor asked CNA G what interventions are in place for R41's heel wound, CNA G said he has a treatment the nurses do. Surveyor asked CNA G if they document refusals of care, CNA G said I think so, we tell our nurse. On 7/15/21 at 1:29 PM, Surveyor interviewed LPN C. Surveyor asked LPN C what interventions are in place for R41's heel wound, LPN C stated we stopped shoes, only to wear gripper socks, elevation of heels as he tolerates, repositioning, GEO-mattress which is graded for pressure injury, up to stage 3. Surveyor asked LPN C if right heel wound just became hard brown eschar this week per the Skin Care Flow Sheet as it documents the wound was deep purple until this week, LPN C stated yes, that is accurate, just became a dry cap of eschar this week. Surveyor asked LPN C if there is documentation of RCA for R41's development of his wounds, LPN C stated no, we had a verbal discussion and review of room etc, but there is no documentation. On 7/15/21 at 2:56 PM, Surveyor interviewed DON B. Surveyor asked DON B if there should be documentation of refusal/non-compliance with interventions, DON B said yes, should be in the computer notes. Surveyor asked DON B if the CNA's have a place to document refusal/non-compliance, DON B said they can write it on their care guide and give it to the nurse. Surveyor asked DON B about the order that said to Document every shift on acceptance and refusals . DON B said yes that is in the TAR. Surveyor asked DON B how to know if their initials mean that R41 accepted or refused from the TAR, DON B said you can't tell if refused or accepted from that. Surveyor asked DON B if there was risk versus benefits completed with R41 or his responsible party, DON B said she would need to double check. Surveyor asked DON B if there is documentation of RCA for R41's development of his wounds, DON B stated LPN C handles all the wound stuff, we discuss wounds every day, she completes the skin sheets every week, the CNA's report skin concerns right away, the nurses check with the CNA's, and we follow our facility policy. It is important to note that no additional information was given to the Surveyor in regard to a risk versus benefit being completed with R41. It is also important to note that the Facility is not following their facility policy in regard to ensuring each facility acquired wound has a RCA completed. Example 3 R6 is a [AGE] year-old, long term resident of the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's most recent quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 4/5/21 indicates R6 has a BIMS Score (Brief Interview of Mental Status) of 4, indicating severe cognitive impartment. The 4/5/21 MDS also indicates R6 is totally dependent on staff with one-person physical assist for bed mobility. On 7/14/21, at 10:28 AM, Surveyor observed LPN I (Licensed Practical Nurse) complete R6's wound care. LPN I used scissors to cut R6's dirty bandage off of her left calf. Then, without cleaning/disinfecting them, LPN I used the same scissors to cut the new/clean dressing to be placed in wound bed. After the treatment was completed, LPN I took R6's treatment box and scissors out of R6's room and into the medication room where the treatment cart is stored. Surveyor discussed the observation of the scissors with LPN I and asked when the scissors are cleaned. LPN I informed Surveyor all residents have their own treatment box and he still needed to clean the scissors. LPN I had placed the dirty scissors in R6's treatment box on top of clean gauze. LPN I removed the scissors from the box and cleaned them with an alcohol pad and removed top several layers of gauze that the dirty scissors had been sitting on. Surveyor asked LPN I if he should have cleaned the scissors in between cutting off the dirty dressing, and LPN I stated, I cut the dressing at the top part of the shin, not where the wound would be, but I can see your point about why they should be cleaned. On 7/14/21, at 10:30 AM, Surveyor spoke with DON B (Director of Nursing) regarding wound care and scissor cleaning. DON B agreed that scissors should be disinfected after being used and before being used on a clean dressing.

Based on interview and record review the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice for 1 of 15 sampled residents (R41) reviewed for change of condition. R41 had a change of condition; the facility failed to recognize this change of condition, complete a comprehensive nursing assessment, assure adequate fluid intake, monitor total fluid intake, monitor increased stool output, complete daily weights as ordered and ensure R41 received the medication to treat C-diff ([CONDITION(S)]-bacteria in the gut which causes excessive liquid stooling) as ordered. This resulted in R41 being hospitalized with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (Rhabdomyolysis is a breakdown of muscle tissue that releases a damaging protein into the blood, this protein is damaging to the kidneys.) From March to April R41 had an 18 lb. (pound), 10.47% weight loss due to severe diarrhea and fluid loss related to infection with C-diff. This is evidenced by: The Facility's Policy and Procedure entitled Change in Residents Condition/Status: Resident, Physician and Family/Legal Representative Notification/Consultation, with a revision date of 4/18, documents in part: .3. For conditions that require immediate notification and consultation, the licensed nurse will complete a comprehensive resident assessment/review and use the SBAR (Situation, Background, Assessment, Recommendation) form to collect all pertinent data. The licensed nurse will have the SBAR and any other necessary information (i.e. medical record, MAR (medication administration record), TAR (treatment administration record), etc.) .7. The Licensed Nurse will record in the resident's medical record any changes in the resident's medical condition or status .9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted . Bristol Stool Chart: Type 1- Separate hard lumps, like nuts (hard to pass), Type 2- Sausage -shaped but lumpy, Type 3- Like a sausage but with cracks on its surface, Type 4- Like a sausage or snake, smooth and soft, Type 5- Soft blobs with clear-cut edges (passed easily), Type 6- Fluffy pieces with ragged edges, a mushy stool, Type 7- Watery, no solid pieces ENTIRELY LIQUID. R41 is a long term resident of the facility. R41 has the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R41's Nurses Notes document the following, in part: 3/16/21 at 1:55 AM Illness Related Stress: Coping poorly: Adjusting poorly: anger denial; Resident ability to self-care has been declining. He has not accepted this very well, and will not call for assistance most of the time. Of note, the facility documents R41's decline in self-care. 3/16/21 at 10:24 PM Has no acute or chronic condition and is not at end stage of disease .Bowel movement by one number 4 of Bristol stool chart (smooth, soft BM) . It is important to note this note is the first time there is mention of R41's stool in the reviewed record. 3/18/21 at 1:56 PM .incontinent of stools . 3/19/21 at 6:14 AM .LLS x 1 . (large loose stool) 3/19/21 at 7:03 PM .Poor dietary intake at breakfast and lunch, however, 240 milliliters liquid ingested at both meal times . Of note, R41 is noted to have a LLS and poor dietary intake. There is no evidence in the medical record indicating a gastrointestinal (GI) assessment was performed. 3/19/21 at 9:49 PM .bowel incontinence by one, resident refused supper; 240 milliliters fluid ingested . Of note there is no indication in the medical record a GI assessment was performed after R41 was noted to have poor intake for breakfast, lunch and dinner. There is no evidence the facility encouraged fluid intake or created a care plan for poor nutritional intake and signs and symptoms of GI illness. R41's meal and fluid intake on 3/19/21= breakfast 50% with 240 mL; lunch 75% with 240 mL; supper 100% with 240 mL. It is important to note nurse's documentation for this date state R41 ate poorly for breakfast and lunch and refused supper. 3/20/21 at 9:26 PM .bowel incontinence by two, type five of Bristol stool chart (soft, blobs of stool); resident resistive to staff, refuses hygiene care by two, consented by one .dietary intake adequate, tolerating fluids . 3/21/21 at 9:28 PM .More frequent bowel movements . Of note, staff recognized R41 was having more frequent bowel movements yet staff did not complete a GI assessment, or contact R41's physician related to R41's change of condition related to (r/t) s/s of GI illness. 3/22/21 at 11:06 AM Call placed to: Attending Physician .Regarding: Resident presenting with being hunched over in wheelchair this AM, offensive smelling feces, resident refusal to eat adequate amounts of his breakfast, resident denying pain or feeling unwell. Vital signs Temperature 98.7, pulse 85, respiration 18, blood pressure 117/85, spo2 99% (oxygen saturation). Of note, R41 first presented with s/s of GI illness on 3/19/21 there was no GI assessment and the physician was not notified of this change in condition until 3/22/21 when R41 presents hunched over in his wheelchair (w/c) with foul smelling stool. Staff did not create a care plan for this change of condition including the need to monitor intake and output (I&O) push fluids related to (r/t) increase fluid loss from frequent bowel movements and decreased oral intake. 3/22/21 at 3:49 PM Bowel Assessment: New onset of incontinence (increased) .Bowel Elimination Patterns .Physical Assessment .Bowel History .Medical conditions .Fecal Incontinence Assessment .Type of Problem: increased type 5 BM incontinence r/t (related to) increased dairy intake, Treatment: Referral to dietician for other snacks versus dairy a bowel diary would not be appropriate at this time as resident toilets self, will not report and has poor recall. 3/22/21 at 4:32 PM Doctor would like R41 to be checked out for C-diff 3/22/21 at 9:20 PM .Resident remains tolerating small amounts of dietary intake, however adequate fluid intake continues . R41's meal and fluid intake on 3/22/21= breakfast 75% with 240 mL; lunch 25% with 240 mL; supper 75% with 240 mL. It is important to note that the nurse's documentation for this date says R41 taking in small dietary intake. 3/23/21 at 8:39 AM weight 172 lbs. 3/23/21 at 3:17 PM lab order placed for stool C-diff . Vital signs were completed and WNL's (within normal limits). Per fax on 3/24/21 start [MEDICATION(S)] 124 mg (milligrams) po (by mouth) 4 times daily for 10 days for C-diff [CONDITION(S)] treatment. Start contact isolation as per your protocol ([MEDICATION(S)] is an extremely powerful antibiotic used to treat infections.) R41 meal and fluid intake on 3/23/21= breakfast 100% with 240 mL, lunch 0% with 240 mL, supper 75% with 240 mL. 3/25/21 at 6:02 AM .Resident had 1 LL (large loose) runny stool . R41's care plan was updated on 3/25/21 with the following information: Problem Diarrhea, Related to: infectious process secondary to C-Diff enteritis, Manifested by: constant dribbling of stool, positive stool culture, Approach .Consult with dietician for client specific advice. Bristol stool chart to be completed and recorded after each bowel movement. A daily review of severity and frequency of diarrhea to be completed and update MD (Medical Doctor) if change noted. Document fluid intake and attempt to monitor output if able as resident does toilet self at times . It is important to note that there is no documentation that the Bristol stool chart was completed and recorded. There is also no documentation of a daily review being completed. 3/25/21 at 2:56 PM .Dr .to update on R41 with his increase in loose stools and decrease in fluid intake d/t (due to) C-diff. R41 was given option of having an IV started .The second option was being sent to the ER (emergency room ) for eval (evaluation) .R41 appeared pale gray, facial features were sinking in and he appeared to have lost weight. He was becoming more confused and agitated. 3/25/21 at 10:46 PM .Resident seen at local emergency room : left hip pain diagnosed . Emergency Department records dated 3/25/21: .Problem- Hip pain, left .diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 3/26/21 at 4:58 AM .Resident hard to arouse. The facility did not complete an assessment or consult with R41's Physician despite noting R41 hard to arouse. 3/26/21 at 6:03 AM .Resident had runny foul smelling LLS . 3/26/21 at 10:46 AM Fax sent .Monitoring order related to current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) Vitals Treatment: Check BP/Pulse/Resp/Temp/O2 every shift. 3) Vitals Treatment: Check Weight daily in AM. Of note the facility receives an order to monitor weight daily and intake every shift. It should be noted R41 weighed 172 pounds on 3/23/21. Daily weights are not performed after this order was received. R41's first weight after experiencing this multi-faceted change of condition was on 4/14/21 where he was noted to weigh 154 pounds. As of 4/14/21, R41 had lost 18 pounds, for a 10.47% weight loss in less than 1 month. It should be noted this large amount of weight loss over a short period of time is related to excess fluid loss. R41's initial Dietary assessment dated [DATE] documents in part: .total fluids: 1950-2340 (25-30mL/kg) (mL= milliliter, kg kilogram) Admit wt. (weight) 172.6 lbs .5) BM pattn (bowel movement pattern) concerns: no problems . Of note R41's fluid intake began to be monitored 3/26/21: 3/26/21 at 10:27 PM .fluid intake adequate, poor dietary intake, referred to the food as feces . 3/26/21 at 10:29 PM .fluid intake adequate . 3/26/21 at 11:23 PM Intake= 0, no output recorded 3/27/21 at 3:48 PM .tolerating adequate amounts of fluids . 3/27/21 at 10:21 PM .tolerated adequate amounts of dietary intake and fluids . 3/27/21= breakfast 0% with 0 mL, lunch 25% with 120 mL, supper 25% with 360 mL. This date is the beginning of poor dietary intake and decreased fluid intake. 3/27/21 at 5:29 AM Output= 1 3/27/21 at 3:22 PM Intake= 360, output= 2 3/27/21 at 8:57 PM Intake= 480, no output recorded- 3/27/21 at 9:24 PM Intake= 360, output= 2 Of note R41's daily intake for 3/27/21 is 1240 ml's below the daily need of 1950-2340 ml/day. 3/28/21 at 12:25 PM .Physician on call 1055, Facial puffiness and swelling of hands go ahead give the [MEDICATION(S)], get him up out of bed and moving around to see if the swelling is position or something else. Vital signs Temperature 98.0, pulse 75, respiration 18, blood pressure 101/52, spo2 98% R41 meal and fluid intake on 3/28/21= breakfast 0% with 120 mL, lunch 50% with 120 mL, supper 100% with 360 mL 3/28/21 at 1:08 AM Intake= 0, output= 1 3/28/21 at 6:30 AM No intake recorded, Output= 2 3/28/21 at 3:10 PM Intake= 480 3/28/21 at 8:31 PM Intake= 600, output= 2 - Of note R41's intake total for 3/28/21 is 1080 below R41's daily intake need of 1950-2340 ml/day. 3/29/21 at 12:59 AM Intake= 0, output= 1 3/29/21 at 9:20 PM Intake= 480, output- 1 3/29/21 at 11:55 PM Intake= 480, output= 2 Of note R41's intake total for 3/29/21 is 960 ml below R41's daily intake need of 1950-2340 ml/day. 3/30/21 at 3:12 PM .remains on isolation precautions for dx (diagnosis) of C Diff .no stooling . R41 meal and fluid intake on 3/30/21= breakfast 25% with 240 mL, lunch 50% with 240 mL, supper 100% with 360 mL 3/30/21 at 1:02 AM Intake= 0, output= 1, BP= 127/64, pulse= 101 3/30/21 at 1:43 PM Intake= 480, output= 3 3/30/21 at 3:22 PM Intake= 480, output= 1 3/30/21 at 11:09 PM Intake= 0, output= 1 Of note R41's intake total for 3/30/21 is 960 ml below R41's daily intake need of 1950-2340 ml/day. It is important to note that the facility did not total R41's daily intake in order to assess the amount of fluid intake R41 was consuming in comparison to the number of bowel movements and urinary output. Monitoring intake and output per the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Without daily totals the staff were unable to assess whether R41 was meeting his daily fluid intake needs. R41 did not meet his daily fluid intake needs. 3/30/21 at 10:38 PM .observed on floor at 9:30 PM .laceration to left brow .called 911 .Will toilet resident immediately after dinner .Reassess toileting schedule Reassess toileting pattern .Resident was trying to toilet himself after dinner. 3/31/21 at 8:29 AM Call placed .Call received at 0825 (8:25 AM) that they were going to keep him for one more day for rhabdomyolysis dehydration to ensure adequate fluid intake via IV (intravenous) therapy . Hospital records date 3/31/21 through 4/1/21: R41 .was brought into the emergency department by EMS (Emergency Medical Staff) on the evening of 3/30/21 after a reported fall in which the patient was found down for an unknown about of time. It is noted that this patient comes from a nursing home and there should be some estimate of how long the patient was down but this was not able to be obtained .He was recently seen in our emergency department on March 25 after family was concerned that he was not eating or drinking well with diarrhea. In the ER that day, it was noted he had just been diagnosed with C. difficile on 3/24/21 and was receiving adequate treatment with oral [MEDICATION(S)]. The patient came in smelling of stool but did not have a bowel movement during his ER visit and drank a 7 up and Gatorade during his stay without difficulty. He was also given IV hydration prior to being discharged back to the nursing home .Mild rhabdomyolysis- Patient was given 1 L (liter) of normal saline in the ER and continued with IV hydration overnight .C. difficile infection- Patient was on oral [MEDICATION(S)] prior to arrival however it was noted that he had completed his course on the 29th which would only be a 5-day course and recommendations are for [MEDICATION(S)] p.o. to be a 10-day course for C. difficile infection. Due to this the [MEDICATION(S)] has been continued and will be completed on 4/6/21 .[MEDICATION(S)] was extended to the appropriate duration of treatment (10 days) . 4/1/21 at 7:55 PM Readmission .Seen in emergency department lab work showed elevated [MEDICATION(S)] kinase (is an enzyme expressed by various tissues and cell types, normal range is 22 to 198, high levels indicate muscle damage due to chronic disease or acute muscle injury) CK 991, on discharge CK down to 429, resident also treated with intravenous fluids normal saline for mild rhabdomyolysis . R41's care plan was updated on 4/2/21 with the following information: Approach R41 is at risk for Rhabdomyolysis related to current use of [MEDICATION(S)] for diagnosis [CONDITION(S)] [CONDITION(S)]- Symptoms include trouble moving arms and legs; and dark red or brown urine or decreased urination. Alert MD immediately if any symptoms noted . R41 experienced a change in condition when he presented with s/s of GI illness. The facility failed to assess R41 when he presented with a change of condition, failed to monitor and total daily fluid intake needs, monitor increased bowel movements, complete daily weights, and ensure R41 received the medication to treat the C-diff as ordered. While R41 was hospitalized from 3/30/21 through 4/1/21 he was diagnosed with rhabdomyolysis which is a medical emergency. From March to April R41 had an 18 lb. (pound), 10.47% weight loss, as a direct result of his GI illness. Weight loss of this amount in this timeframe is in direct relation of inadequate hydration. On 7/14/21 at 1:27 PM, Surveyor interviewed LPN C (Licenses Practical Nurse). Surveyor requested documentation of R41's bowel movements for February through April. LPN C returned with documentation of stools for only April. Surveyor asked LPN C where the documentation is for February and March, LPN C stated We did not track BM's in February or March d/t R41 toileting self independently. On 7/14/21 at 1:59 PM, Surveyor interviewed CNA F (Certified Nursing Assistant). Surveyor asked CNA F how R41's stools were before he got C-diff, CNA F said he was regular, he'd ask for prune juice a couple times a week, he'd know if he was bound up. Surveyor asked CNA F what the consistency was of R41's BM's, CNA F replied I think he may have been on the looser side. Surveyor asked CNA F if R41 had more frequent stools once he had C-diff, CNA F stated I don't know if he went more after the C-diff. On 7/14/21 at 2:37 PM, Surveyor interviewed RN E (Registered Nurse). Surveyor asked RN E how R41's stool were before he got C-diff, RN E said they were a little loose before he was tested . Surveyor asked RN E what was R41's bowel pattern prior to C-diff, RN E said R41 was regular and 4 on Bristol. Surveyor asked RN E when his stools were more loose, what were they on the Bristol chart, RN E replied Bristol 6. Surveyor asked RN E if R41 had any other changes in his bowel patterns, RN E stated he was having more frequent stools. RN E stated didn't think it was C-diff because it wasn't Bristol 7. When Surveyor asked RN E once R41 was diagnosed with C-diff, what measures were put into place, RN E stated we pushed fluids, but R41 does pretty good with fluids if you hand it to him and ask him to drink it, frequent checks, isolation, and we sent him out to ER, they wanted to keep him but he refused admission. Surveyor asked RN E if pushing fluids was documenting anywhere. RN E said no that's given as verbal report. On 7/15/21 at 10:09 AM, Surveyor interviewed RN D. Surveyor asked RN D if a resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor asked RN D how does the facility complete weights, RN D explained that the CNA's complete the weights and they are entered by dietary. Surveyor asked RN D who's responsible for assessing the weights and consulting the Physician. RN D said nursing is responsible for identifying if weight has gone up or down, the computer triggers it. Surveyor asked RN D if the nurses charting and the CNA's charting (meals, fluids, stools) should match, RN D replied yes except that the nursing may have more for fluids r/t adding med pass fluids to dietary fluids. On 07/15/21 at 2:10 PM, Surveyor interviewed CNA O. Surveyor asked CNA O how they monitor I/O, CNA O said they record meal intakes, food and fluid on the document entitled Intake Record. On 7/15/21 at 2:17 PM, Surveyor interviewed RN D. Surveyor asked RN D who totals the I/O and evaluates it? RN D said the nurses total it so they can add their own med pass in there. On 7/15/21 at 2:56 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if a resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . DON B stated yes, they should. Surveyor asked DON B if she expects her nurses to review the whole person (i.e. appetite, fluid intake, stools, medications, past history, etc.) when they're having a change in status. DON B replied yes. Surveyor asked DON B who should complete I/O when it is ordered. DON B explained the CNAs record on meal intake and fluids at meals, the nurses record what they give in the TAR, and the nurses should total and look at that. Surveyor asked DON B where should the daily total be recorded. DON B said the total should be in the computer. Surveyor asked DON B if the nurses charting and the CNAs' charting (meals, fluids, stools) should match, DON B stated Typically you would think so.

Based on observation, interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 residents (R3) reviewed for supervision and accidents out of a total sample of 7. R3 is moderately cognitively impaired, and requires extensive assist of two staff with transfers. R6 assisted R3 with a transfer that resulted in R3 falling and sustaining three fractures to the left leg. The facility was aware that R6 would attempt to assist residents and did not put interventions in place to prevent R6 from assisting R3 resulting in a fall with a fracture. This is evidenced by: The facility's Fall Assessment and Prevention Protocol, revised 10/2017, states as follows: Purpose: A comprehensive, proactive falls assessment will be conducted at the time or resident admission to the skilled nursing facility. If/when a resident experiences a fall, root cause analysis will be conducted to assist in planning appropriate evidence-based interventions to prevent further falls. Protocol: After a fall or intercepted fall: (*an intercepted fall is defined as an episode where a resident lost his or her balance and would have fallen, were it not for staff intervention.) 1. Ensure that the resident needs are met and the resident is safe. Make them comfortable. Attend to any immediate medical needs and provide appropriate intervention. Assess the scene and begin the Fall Scene Investigation Report, a root cause analysis tool for falls that looks at internal environmental and operational/systemic conditions that may have contributed to/been responsible for the fall. 5. Complete a new fall assessment in ECS (Electronic Charting System) and discuss the new intervention that was immediately implemented. 6. Update the resident care plan in ECS with the appropriate intervention(s) to keep resident safe until reviewed by interdisciplinary team the following business day. 7. Add any new interventions to the CNA assignment sheets and to the 24-hour report to communicate any new resident needs. Assign responsibility to an appropriate staff person to implement any new resident safety equipment identified through this process. If necessary, the Resident Safety and Assistive Device Use Acknowledgement will be completed at this time. 8. The interdisciplinary team (IDT) will review the above items the following business day to ensure appropriateness, and make/document any necessary changes. Ongoing 1. In addition to the above procedure, all residents who have had actual falls will be reviewed at PAR (Persons at Risk) meeting weekly, a subcommittee of Quality Assurance and Performance Improvement (QAPI) committee. 2. Any trends or patterns in falls will be evaluated through the facility QAPI process on a monthly/quarterly basis. 3. All staff members are regularly educated on resident fall prevention and safety, including proper placement of safety devices, use of different kinds of available safety equipment, and daily surveillance of possible hazards. 5. Education and communication with the resident, family and/or their legal representatives is vital to ensuring a balance between reasonable safety goals and an optimal resident quality of life. R6 was admitted to the facility on [DATE] with diagnoses that include in part . Unspecified dementia without behavioral disturbance, anxiety disorder, need for continuous supervision. R6's Annual MDS (Minimum Data Set) dated 1/08/21 indicates that R6's BIMS (Brief Interview of Mental Status) is 8 indicating moderate cognitive impairment. R6 has an AHCPOA (Activated Healthcare Power of Attorney). Section G0110, Functional Status Transfers: Independent no help from staff, Locomotion on Unit: Independent no help from staff, Dressing: Independent no help from staff, Toileting: Independent no help from staff. Section G0300 Balance During Transitions and Walking, Moving from seated to stand position: Independent no help from staff, Surface to Surface transfers (transfer between bed and chair or wheelchair): Independent no help from staff. R6's Comprehensive Care Plan, dated 3/22/21 states in part . Problem: Disruptive interaction with other residents. Related to: Impaired Cognition. Manifested By: Helping other residents transfer out of chairs and pushing other residents in their wheelchairs. Nurse/Nurse Aide: Maintain safety of resident and other residents, and other staff, praise positives, provide calm environment, 3/19/21 redirect R6 when she attempts to help other residents transfer and push them in their wheelchairs, remind R6 often to get staff to do the transfers. R6's CNA (Certified Nursing Assistant) Assignment Sheet printed 3/23/21 states in part . 3/19/21, redirect R6 when she attempts to help other residents transfer and push them in their wheelchairs. R6's TAR (Treatment Administration Record) dated 3/22/21 states: Target Behavior for: Attempting to assist other residents needing redirection. Signed out every shift. R6's Behavior 10-day tracker with dates ranging from 3/19/21 to 3/22/21 indicates the following: Physical behavioral symptoms directed toward others includes assisting. A number 1 indicates symptom presence and a 0 indicates not present. 3/19, 3/20, 3/21 all indicate 0 (not present), 3/22 indicates a 1 on day shift with notes stating, wheelchair wanting to assist. R3 was admitted to the facility on [DATE] with diagnoses including: history of falling (dated 7/09/14), malaise and fatigue, dehydration, obesity, anorexia, [CONDITION(S)], unsteadiness of feet, muscle weakness. R3's Quarterly MDS (Minimum Data Set), dated 1/07/21, indicated R3's BIMS (Brief Interview for Mental Status) is 99, indicating she is unable to complete one or more questions of the interview (previous MDS from 10/07/20 was 8, indicating moderate cognitive impairment). R3 is her own person. Section G0110, Functional Status Transfers: Extensive assist of 2, Locomotion on Unit: Independent no help from staff, Dressing: Extensive assist of 1, Toileting: Dependent assist of 2, section G0300 Balance during Transitions and Walking Moving from seated to stand position: Not steady, only able to stabilize with human assist. Surface to surface transfer (transfer between bed and chair or wheelchair): Not steady, only able to stabilize with human assistance. R3's Comprehensive Care Plan, Problem: Potential for Trauma-Falls, dated 8/15/19, updated 3/19/21, states in part . Encourage to ask for assistance, call light in reach, and assist with ambulation, transfers, and toileting. Do not leave unattended when toileting. Anticipate needs, dycem non-skid mat between resident clothing and wheelchair surface. Return to bed at preferred time. Education done with CNA staff - Hoyer lift assist of 2. Assure proper placement of all extremities prior to and during transfers. Fall 3/18/21 On 3/18/21 at 6:15 PM, R3 was observed on the floor. Location: Resident's room; Activity at the Time: Transferring Equipment: Recliner Mental State: Normal for resident; Injury: Suspected fracture Location: Left lower leg. Transferred to emergency room . Actions: Intervention applied immediately to prevent recurrence: Re-assess roommate status. Assessment Supporting Intervention: Roommate verbalized to staff that she was trying to assist resident out of recliner. Describe what happened. Statement of observation when resident found. Resident sitting on floor, upper torso on recliner situated behind her, right leg extended, left lower leg rotated outward from the midline of her body. Resident was wearing blouse, long skirt that was bundled at mid-thigh and gripper socks on both feet. What resident stated regarding fall: Initially resident just giggled continuously and denied pain. She later told the ambulance attendances that she was trying to get up and fell . Describe why it happened: Behavior prior to fall: Normal for resident; sitting in recliner. Call light in reach: Yes. Safety Equipment Functioning Properly: Yes. Inappropriate Footwear: No. Assistive device used per care plan? Yes. Care Plan followed: Yes Describe What Caused Incident: Root cause identified: Roommate verbalized to staff that she was trying to get resident up to take her to supper. Resident Injury/Outcome: Suspected Fracture Resident Comments Regarding Incident: Roommate: I was trying, she is a bigger person than me, then I left the room, when I looked back she was on the floor. I did not see it. Steps to Prevent Recurrence: Re-assess roommate status. R3 was transferred to the Emergency Department for evaluation on 3/18/21 at 6:49 PM. Head CT (x-ray scan of head) and 2 view x-ray of the tibia and fibula were conducted. Head CT showed no abnormalities. X-ray of the tibia and fibula completed at the hospital on 3/18/21 indicates: 1. Large mildly comminuted and angulated fracture of the proximal met-diaphysis, extending to the proximal to mid diaphysis (broken leg) 2. Proximal fibula fracture extending from the fibular head/neck to the mid fibular diaphysis as described above (broken leg). 3. Other chronic findings including osteopenia (thin bones) and [CONDITION(S)] (age related changes) changes at the knee and ankle/hind foot. R3 returned to the facility on [DATE] at 10:26 PM. R3's left leg was placed in a temporary cast, R3 requested no other treatment for the fractures. Nurses Note dated 3/22/21 entered by DON B (Director of Nursing) states, Resident returned to the facility and was immediately placed in a private room. On 3/23/21 at 1:22 PM, Surveyor interviewed R3. Surveyor asked R3 if she was having any pain. R3 denied. Surveyor asked R3 what happened to her leg. R3 states that she fell trying to get up too fast. Surveyor asked R3 if anyone was assisting her when she fell , R3 stated, No. On 3/23/21 at 3:27 PM, Surveyor interviewed RN F (Registered Nurse). Surveyor asked what RN F could tell her about R6. RN F indicated one of her new care plans is to have staff intervene. I used to work nights and came to days in January. R6 has always been trying to assist other residents. R6 will usually push R3 back from the dining room and we would need to intervene. Nothing has ever happened prior to this. I have never seen her do anything other than trying to push other residents in their wheelchairs. We are to be monitoring her more closely. At 5:14 PM, Surveyor interviewed RN F again. Surveyor asked RN F if she could tell me what monitoring R6 means. RN F stated, If within eye sight we are to watch her more closely. Redirect if needed and ask if she needs anything herself. On 3/23/21 at 3:32 PM, Surveyor interviewed CNA G (Certified Nursing Assistant). Surveyor asked CNA G what she could tell me about the incident with R3 and R6. CNA G stated, R6 is trying to assist others all the time. I try to redirect her but that only works depending on her mood. Surveyor asked CNA G if anything has ever happened prior to this incident. CNA G stated, Nothing has happened prior to this but a couple of weeks back she asked me about getting R3 out of bed so she was hinting. Surveyor asked CNA G what was being done so that R6 does not do this again. CNA G stated, R6 is not allowed in R3's new room, they were separated, don't quote me but I think that is it. At 6:40 PM, Surveyor interviewed CNA G again. Surveyor asked what CNA G's definition of monitoring is for R6. CNA G stated, Just check on her when I can. On 3/23/21 at 3:38 PM, Surveyor interviewed CNA E. Surveyor asked CNA E about the incident from 3/18/21. CNA E stated, R6 is known to help people a lot. R6 came out of their room and asked me to assist her with transferring R3 to the wheelchair. I followed R6 to their room and found R3 sitting on the floor in front of her recliner. R6 then said she was trying to assist R3 up into her recliner for supper. Surveyor asked CNA E if he had ever witnessed R6 trying to assist R3 prior to this incident. CNA E stated, I caught R6 trying to get R3 out of bed before. Surveyor asked CNA E if he told anyone about that. CNA E stated, Yes, I told the floor nurse on duty. I have also seen R6 go into other rooms to do that or help push others down the hall in their wheelchairs. R6 thinks she works here. Surveyor asked what they are doing to prevent R6 from helping others in the future. CNA E stated, No other roommates and we are to remind her not to help others. On 3/23/21 at 5:25 PM Surveyor interviewed CNA E (Certified Nursing Assistant) regarding monitoring R6. CNA E indicated staff are redirecting her when seeing her trying to help others. CNA E indicated that R6 does not have a roommate at this time and that he's to deter her from helping others. CNA E indicated staff are to try to keep an eye on her and check up on her every 30 (thirty) minutes or so. Surveyor asked CNA E if that was on R6's care plan. CNA E pulled out his CNA Care Plan/Care Guide and Read R6's Care Guide to me. CNA E indicated checking up on R6 is not on his care plan for her. CNA E indicated nothing is on there except to redirect resident when trying to push others in their wheelchair. On 3/23/21 at 3:45 PM Surveyor interviewed LPN D. Surveyor asked LPN D if she was aware that R6 liked to assist R3. LPN D stated, I have redirected R6 a few times from pushing people in their wheelchairs but other than that nothing. Surveyor asked LPN D what staff are doing to prevent R6 from assisting. LPN D stated, We are monitoring her daily, more activities, and just spending extra time with her. On 3/23/21 at 3:47 PM, Surveyor interviewed DON B. Surveyor asked DON B what she could tell Surveyor about the incident with R3 and R6 on 3/18/21. DON B stated, On the 18th the nurse on duty called stating R6 had attempted to assist R3 out of her recliner and she fell . I talked with the other staff on duty. When I talked to CNA G he stated he overheard R6 talking to another resident that she was helping R3 get up for supper. CNA G went to R3's room and found her on the floor. R3's right leg was extended and her left leg was rotated midline. R6 is easily redirected. Surveyor asked what staff are doing to prevent R6 from helping others. DON B stated, We are keeping an eye on her. She is not going to be having a roommate at this time and document behaviors. Surveyor asked DON B if R6 was known for assisting other residents including R3. DON B stated, When I looked into this and interviewed staff, they stated, No and that they have just caught R6 next to R3's bed uncovering her. Last week I witnessed her pushing another resident in their wheelchair and I intervened right away. On 3/23/21 at 5:21 PM, Surveyor interviewed Activities H. Surveyor asked Activities H about the incident from 3/18/21 between R3 and R6. Activities H stated, I wasn't here but R6 is always very helpful with R3. Surveyor asked Activities H if she had ever witnessed R6 assisting other residents or R3 prior to this incident. Activities H stated, 'I probably have seen it prior but never saw it as problematic. Surveyor asked Activities H what staff are doing to ensure R6 is not assisting others. Activities H stated, 'We are to be monitoring her. Surveyor asked what monitoring R6 consisted of. Activities H stated, If see R6 assisting others, intervene and help the person she was trying to help. On 3/23/21 at 5:04 PM Surveyor interviewed RN C. Surveyor asked RN C what she could tell Surveyor about the incident from 3/18/21 with R6 and R3. RN C stated, I know R6 attempted to transfer R3 from her chair to either her wheelchair or bed. I wasn't here but was told about it the next day. Surveyor asked RN C if this was something R6 had ever done previously. RN C stated, I didn't think R6 would help someone transfer. She likes to be busy and help but I didn't think she would do that. I have seen her push residents including R3 in their wheelchairs and have stopped her and redirected her. Surveyor asked RN C when was the last time you saw R6 trying to assist someone. RN C stated, Just yesterday (3/22/21) she was pushing another resident, not R3, in their wheelchair. Surveyor asked RN C what staff was doing to ensure R6 was not assisting residents. RN C stated, We are redirecting R6. We are trying to keep her occupied. R6 was seen by a provider today and I haven't seen her up doing anything today. We are monitoring her but I don't believe any checks are in place, just if you see her redirect her. On 3/23/21 at 5:06 PM Surveyor interviewed LPN D (Licensed Practical Nurse) regarding R6. LPN D indicated that when she walks by R6, she tries to keep her busy with activities. LPN D indicated that she would monitor what R6 is doing and where she is. LPN D indicated monitoring to her meant keeping an eye on her (R6) with frequent checks and R6 is not on checks or line of sight. LPN D indicated staff let each other know where she's at without keeping her in the line of sight. LPN D indicated currently staff are to redirect R6 and educate R6, but is she going to remember, no, so redirecting to tasks and activities. LPN D indicated activities such as folding towels or letting her clean off a table with a dry rag as she stops at the desk to see if she's on the schedule as R6 is a firm believer that she works here. On 3/23/21 at 5:12 PM Surveyor interviewed R6. R6 was sitting in her recliner in her room at this time. R6 indicated that she walks a lot, works on crafts and makes meals throughout the day to keep busy. Surveyor asked R6 about her last roommate, R6 indicated that her last roommate was a [NAME] who took all of her stuff. R6 got up from her recliner at this time without any balance problems or needing to push up off the chair and went over to her dresser to show Surveyor all the items her roommate went through. R6 indicated if she needed help she's to put on light or she goes down to the desk but they have so many bare beds. Surveyor asked R6 if she helps others and R6 indicated they don't want you to do that in case something were to happen, but I go in and visit with them. The facility failed to put interventions in place to prevent R6 from assisting other residents despite staff having knowledge this was occurring. R6 transferred R3 which resulted in R3 falling and sustaining 3 fractures to the left lower leg.

Based on observation, interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 3 of 5 residents (R48, R5, R51) reviewed for supervision and accidents. R48 is severely cognitively impaired, and has a history of transferring independently despite being care planned as requiring assistance with an EZ stand. The facility did not provide risk/benefits to R48 and/or her APOAHC (Activated Power of Attorney for Health Care) regarding the risks related to self-transferring. R48 sustained a total of 5 falls on the following dates: 10/28/20, 10/30/20, 11/13/20, 12/21/20, and 12/26/20. On 10/30/20 after self-transferring R48 required (9) sutures and (5) staples to her head. With all 5 falls, the facility did not re-assess R48 and update R48's care plan after the falls occurred. The facility did not ensure that R48's care plan interventions for safety and supervision were being followed, did not educate staff, determine the root cause, and did not thoroughly investigate the falls. The facility did not obtain witness statements for any falls, including those involving the EZ stand, and had not updated R48's fall care plan since August 2019. R5 eloped from the facility. The facility did not have evidence that R5's care plan was updated with new interventions after this event on 11/29/20, and there was no evidence of a thorough investigation by the Interdisciplinary Team (IDT) for root cause of this event and plan to prevent reoccurrence. The facility did not have documentation of daily door alarm monitoring in place at the time of the event. On 11/29/20, R5 made two attempts to leave the facility which triggered the door alarm, R5 made another attempt to leave the building and was found outside the building without the door alarm activated. R51 was noted to missing from the facility. The sheriff found R51 across Highway 54 at the American Legion (0.3 miles) and returned R51 to the facility. There was not an investigation, elopement assessment nor documentation of any interventions put into place to prevent this from occurring again. This is evidenced by: The facility's Fall Assessment and Prevention Protocol, revised 10/2017, states as follows: Purpose: A comprehensive, proactive falls assessment will be conducted at the time or resident admission to the skilled nursing facility. If/when a resident experiences a fall, root cause analysis will be conducted to assist in planing appropriate evidence-based interventions to prevent further falls. Protocol: After a fall or intercepted fall: (*An intercepted fall is defined as an episode where a resident lost his or her balance and would have fallen, were it not for staff intervention.) 1. Ensure that the resident needs are met and the resident is safe. Make them comfortable. Attend to any immediate medical needs and provide appropriate intervention. Assess the scene and begin the Fall Scene Investigation Report, a root cause analysis tool for falls that looks at internal environmental and operational/systemic conditions that may have contributed to/been responsible for the fall. 4. Document the fall in the nursing charting tab, incidents folder in ECS, according to the Incident and Investigation Report Procedure. 5. Complete a new fall assessment in ECS and discuss the new intervention that was immediately implemented. 6. Update the resident care plan in ECS with the appropriate intervention(s) to keep resident safe until reviewed by interdisciplinary team the following business day. 7. Add any new interventions to the CNA assignment sheets and to the 24-hour report to communicate any new resident needs. Assign responsibility to an appropriate staff person to implement any new resident safety equipment identified through this process. If necessary, the Resident Safety and Assistive Device Use Acknowledgement will be completed at this time. 8. The interdisciplinary team (IDT) will review the above items the following business day to ensure appropriateness, and make/document any necessary changes. Ongoing 1. In addition to the above procedure, all residents who have had actual falls will be reviewed at PAR (Persons at Risk) meeting weekly, a subcommittee of Quality Assurance and Performance Improvement (QAPI) committee. 2. Any trends or patterns in falls will be evaluated through the facility QAPI process on a monthly/quarterly basis. 3. All staff members are regularly educated on resident fall prevention and safety, including proper placement of safety devices, use of different kinds of available safety equipment, and daily surveillance of possible hazards. 5. Education and communication with the resident, family and/or their legal representatives is vital to ensuring a balance between reasonable safety goals and an optimal resident quality of life. Example 1 R48 was admitted to the facility on [DATE] with diagnoses including: history of falling, fracture left acetabulum, fracture of left pelvis, diabetes mellitus, cognitive decline, [CONDITION(S)], anxiety disorder, abnormal gait, pain left hip, muscle weakness, unsteadiness on feet, [CONDITION(S)] and nocturia (voiding at night). R48's Annual MDS (Minimum Data Set), dated 10/31/20, indicated R48's BIMS (Brief Interview for Mental Status) is 4, indicating she is severely cognitively impaired. R48 has an Activated Power of Attorney. Section G0110, Functional Status Transfers: Extensive assist of 1, Locomotion on Unit: Extensive assist of 1, Dressing: Extensive assist of 1, Toileting: Extensive assist of 1, Section G0300 Balance During Transitions and Walking Moving from seated to stand position: Not steady, only able to stabilize with human assistance. Surface to surface transfer (transfer between bed and chair or wheelchair): Not steady, only able to stabilize with human assistance. Section J1700 indicates R48 has fall history on admission. R48 had falls in the last 2-6 months. R48 is at risk for fall. Note, R1 was admitted with multiple fractures due to a fall. R48's Comprehensive Care Plan, for Trauma-Falls dated 7/24/20 includes, in part: Problem: Trauma-Falls, Related to: Decline in cognitive status, Decline in functional status Manifested By: Fall in her room; fall out of wheelchair. Approach: 8/19/19 Nurses - observe, record, and report all unsafe conditions and situations, Encourage to ask for assistance, Educated staff. 8/19/19 Nurse Aide - Encourage to ask for assistance, Call light in reach, Do not leave unattended when toileting, to wear non-slip footwear instead of regular socks, Offer toileting after meals and auto locks on wheel chair. 8/19/19 All Staff - Maintenance to apply auto locks to wheel chair. Goal: No injury, if a fall should occur. Goal Time: 3/6/21. It is important to note R48's fall interventions have not been updated since August 2019. R48's CNA (Certified Nursing Assistant) Care Card, dated 1/20/21, states as follows: Transfer assist: Assist of 1 EZ stand or Max A x1 (1 person) for transfers, depending upon her level of alertness. Supportive Devices: Wheelchair with Drive Gel Lite cushion; Safety Equipment: gripper socks; Toileting: Supra Pubic catheter: need I (input) and O (output). Assist of 1, incontinent of bowels. Assist with very good peri care, dry thoroughly. Offer toileting every 2 hours and as needed. Special Care Remarks: POA (Power of Attorney Health Care Activated), Glasses, dentures, fall risk For reference, R48's Incident follow-up dated 8/15/19 at 9:07 AM, states as follows: Witnessed fall IDT reviewed incident from 8/14/19. R48 fell in her room while transferring from her wheelchair. She was wearing regular socks, and intervention was to apply gripper socks and ensure that she is wearing appropriate footwear. R48's Falls over the past 6 months : 10/28/20, 10/30/20, 11/13/20, 12/21/20, 12/26/20 Fall 10/28/20 On 10/28/20 at 2:16 PM, R1 was observed on the floor. Location: Resident's room; Activity at the Time: Transferring Equipment: Wheelchair Mental Status: Normal Mental State: Normal; Injury Abrasion right lower arm proximal to wrist 5cm x 1cm (centimeter) First aid: Immediately applied Actions: Intervention applied immediately to prevent recurrence: Resident assisted to toilet; hygiene care provided. Assessment Supporting Intervention: R48 had fecal incontinence. Steps to Prevent Recurrence: Education: staff reminded to offer toileting for bowel movements after meals. Describe equipment involved: Wheelchair Describe what happened: Statement of observation when resident found: Resident was sitting on the floor, both legs extended and arms caught between the side bars of the wheelchair. R48 was wearing a brief and blouse, gripper socks donned. Resident was situated near to the entrance of the toilet, however, she was facing the window of her room. What resident stated regarding fall: I should not have done what I did, I am so sorry. Describe why it happened: Behavior prior to fall: Normal for resident; sitting up in wheelchair Easily fatigued? No Behavior prior to fall: Normal for resident no abnormalities reported. Call light in reach: Yes Safety Equipment Functioning Properly: Yes Inappropriate Footwear: No Assistive device used per care plan? Yes Care Plan followed: Yes Describe What Caused Incident: Root cause identified: R48 has history of confusion; history of trying to ambulate independently at times. Resident Injury/Outcome: Abrasion Resident Comments Regarding Incident: No comments made Injury: Abrasion Steps to Prevent Recurrence: Education: staff reminded to offer toileting for bowel movements after meals. Note: Offering toileting after meals had previously been added to R48's care plan on 8/19/19, over one year prior. The facility did not interview staff, obtain staff statements or investigate the fall. Although the fall report mentions a root cause analysis (RCA) the facility did not use the RCA to determine what may have contributed to the fall such as the need to use the restroom. Fall 10/30/20 On 10/30/20 at 12:30 PM, R1 was observed on the floor. Location: Resident's room; Activity at the Time: Transferring Equipment: Wheelchair Mental State: Normal for resident; Injury: Skin tear and laceration (1) Right hand, Left forearm proximal to elbow 1.0 cm x 1.0 cm, 2.5 cm x 1.5 cm, 0.2 cm x 1.0 cm. Actions: Intervention applied immediately to prevent Recurrence: Resident was laid in bed. Assessment Supporting Intervention: R48 has history of napping in recliner after meals (especially lunch) due to falling asleep in wheelchair. Description of Incident: Statement of observation when resident found: Resident was on the floor, left lateral position left arm under head, right leg flexed over left leg which was extended fully. Resident was wearing long sleeved cardigan, blouse, long pants and gripper socks. Full body lift was used to transfer resident from floor to bed. What resident stated regarding fall: I did another stupid thing. Describe Why It Happened: Behavior prior to fall: Normal for resident sitting up in wheelchair. Easily Fatigues? No Behavior prior to fall: Normal for resident Call light in reach: Yes Safety equipment in place: Yes Safety Equipment functioning properly: Yes Inappropriate footwear: No Assistive device used per care plan Yes. Care plan directive followed: Yes Describe what Caused Incident: Root cause identified: Resident has history of trying to self transfer Resident injury/outcome: Laceration by two, skin tear by two {SIC} Resident Comments Regarding Incident: No comments made Injury: Skin tear, laceration Steps to Prevent recurrence: Lay resident down after meals Note, the Immediate Intervention was Resident was laid in bed. Steps to Prevent Recurrence: Lay resident down after meals. This intervention was not added to R48's care plan. The facility did not interview staff, obtain staff statements or investigate the fall. Although the fall report mentions a RCA the facility did not exam the root cause for the fall to prevent reoccurrence. On 10/30/20 at 2:50 PM, R48's NN (Nurses Notes) state as follows: Resident transferred; Time of transfer: 1:15 PM, transferred to ED (Emergency Department) by ambulance. Reason: for evaluation, history of fall laceration to head possible sutures needed. On 10/30/20 at 5:00 PM, R48's NN state as follows: Return date 10/30/20 Return Time: 4:25 PM via van Pre-Admission Data: History of falling at 12:30 PM; laceration to head by two front and top of head, skin tear to right hand; per hospital staff nine (9) sutures in-situ at front of head and five (5) staples at the back. Complete head wrap with kerlix remains, small amount of blood at frontal area, monitoring continues. {SIC} On 11/2/20 a follow up note indicates: Date Incident occurred 10/30/20 12:30 PM, observed on floor. Additional information: fell forward out of wheelchair and received laceration to head. Sent out to ER (emergency room ) for evaluation. Fall 11/13/20 On 11/13/20 at 6:00 PM, R48 was observed on the floor. Location: Resident's room; Activity at the Time: Transferring Equipment: None Mental Status: Normal Mental State: Normal Actions: Intervention applied immediately to prevent recurrence: Education: reminded resident to use call light for assistance, re-oriented resident to call light. Assessment Supporting Intervention: Resident verbalized: I need help, I can't get no help. Description of Incident: Statement of observation when resident found: Resident's upper torso was on the floor while both leg was on her bed; resident was looking up at the ceiling, right hand on her forehead, left arm reaching up at staff. Resident was wearing long sleeve blouse and brief. What resident stated regarding fall: I don't know, help me up. Describe why it happened: Behavioral prior to fall: normal for resident, eating her supper. Easily fatigued? No Behavior prior to fall: Normal for resident, call light in reach: Yes Safety equipment in place: Yes Safety Equipment functioning properly: Yes Inappropriate Footwear: Gripper socks donned on both feet. Assistive devices used per care plan? Yes Care plan directive followed? Yes Describe What Caused Incident: Root cause identified: R48 has history of trying to self transfer from different surfaces. Resident Injury/Outcome: No apparent injury Resident Comments Regarding Incident: None made Injury: No apparent injury Steps to Prevent Recurrence: Continued education: resident reminders on using her call light, continued rounding on resident, provide varied reading materials. Note, resident reminders on using her call light is not an appropriate intervention for a resident that is severely cognitively impaired. There is no document of rounding on R48. These interventions were not added to R48's care plan. Although the fall report mentions a RCA the facility did not use the RCA to exam the reason for R1's repeated falls. Fall 12/21/20 On 12/21/20 at 11:15 PM, R48's Incidents and Accidents, including follow up, indicates the following: Observed on floor Physician Review: Physician Returned call. Notification: Family returned call. Injury: Skin tear L (left) elbow, Laceration: L forehead, Hematoma: L forehead. Sent to hospital. It is important to note for this fall, there is no Incident Report, investigation, statements obtained by staff, root cause analysis or immediate intervention put in place to prevent future falls. R48's call light was not in reach contrary to her care plan. On 12/22/20 at 8:01 AM, R48's ED report, indicates the following: Chief Complaint: Patient found down on floor by w/c (wheelchair)-unwitnessed fall. Left scalp lac (laceration)/bilateral elbow skin tears. Opens eyes to name called. History of Present Illness: R48 is an [AGE] year old woman with a history of dementia and frequent falls who is presenting via EMS (Emergency Medical Services) for her fall at her nursing home with head laceration. She has baseline dementia and is COVID positive (She tested positive one week ago). She is not on any blood thinners. She will open her eyes spontaneously but does not verbalize. This appears consistent with her last ER (emergency room ) visit. She has had sleeping medication prior to arrival. It is unclear how long she was laying on the floor prior to being found by staff. She is a DNR (do not resuscitate) and comfort care only. Medical Decision Making: R48 does not have any intracranial bleeding. CT Findings: There is no evidence of acute hemorrhage or infarction . Redemonstrated is diffuse enlargement of the lateral and third ventricles concerning for normal pressure [CONDITION(S)]. Periventricular hypodensities most consistent chronic small vessel disease changes. Fall 12/26/20 On 12/26/20 at 10:45 AM, R48 had a witnessed fall. Location: Resident's bathroom; Activity at the Time: Toileting using EZ stand; Equipment: Sit-to-stand lift Mental Status: Positive COVID-19 resident in isolation Description of Incident: None Describe why it happened: None Easily fatigued? No Behavior prior to fall: Normal for resident, call light in reach: Yes Safety equipment in place: Yes Safety Equipment functioning properly: Yes Inappropriate Footwear: Gripper socks donned on both feet. Assistive devices used per care plan? Yes Care plan directive followed? Yes Describe What Caused Incident: None Resident Injury/Outcome: No apparent injury Resident Comments Regarding Incident: None Injury: No apparent injury Steps to Prevent Recurrence: None Actions: Intervention applied immediately to prevent recurrence: Two staff at all times during transfers Assessment Supporting Intervention: Second staff can encourage guidance and safety during transfers using mechanical lift. On 12/26/20 at 2:40 PM, R48's NN indicates the following: Incident Type: Witnessed fall Date of Incident: 12/26/20 at 10:45 AM. Positive COVID-19 resident in isolation. Activity at the time: Toileting using EZ stand. Equipment Involved: Sit-to-stand lift Injury: No apparent injury Injury location: N/A (no applicable) First aid: none needed Vitals: Not taken at this time related to no injuries reported Neuro checked (immediately after incident) Pupils equal, round and react to light. Bilateral hand grasp firm. Staff Involved: CNA Witnesses. Intervention applied immediately to prevent recurrence: two staff at all times during transfers. Assessment supporting intervention: Second staff can encourage guidance and safety during transfers using mechanical lift. Intervention applied immediately to prevent recurrence: Educated staff to be cautious during transfers. Assessment supporting intervention: Staff will be more attentive to resident surroundings. Note, R48's care plan was not updated to require 2 assist for transfers. The facility did not interview staff, obtain staff statements or investigate the fall. There is no page 2/2 for this Incident Report. On 1/21/21 at 11:11 AM, Surveyor observed R48 lying in bed with bare feet. R48 was not wearing gripper socks, contrary to her care plan. On 8/15/19 Gripper socks were added to R1's care plan as a fall intervention after R48 sustained a fall. Surveyor asked CNA L (Certified Nursing Assistant) if R48 should be wearing gripper socks. CNA L stated R48 should be wearing gripper socks. CNA L located gripper socks and put them on R48's feet. On 1/21/21 at 2:30 PM, Surveyor spoke with RC D (Regional Consultant). Surveyor asked RC D if the facility provided risks and benefits to R48 and her APOAHC related to her repeatedly self-transferring. RC D stated she reviewed R48's medical record and there is no evidence that the facility provided risks and benefits to R48 and/or her APOAHC. On 1/21/21 at 2:36 PM, Surveyor spoke with DON B (Director of Nursing). DON B started working at the facility as an RN (Registered Nurse) in April 2020 and became the DON in August 2020. While Surveyor and DON B were meeting, DON B sat at her computer to look up and reference information related to R48's falls, including her CNA care card and comprehensive care plan. Surveyor also shared the printed fall investigations provided by the facility with DON B. Surveyor spoke with DON B regarding R48's fall on 10/28/20. DON B stated R48, tipped her wheelchair forward. Surveyor asked DON B do you know what R48 was attempting to do. DON B stated, It doesn't say in here. DON B added, if I was to ask R48 what happened she would respond to me accordingly. DON B stated the intervention for this fall is to offer toileting after meals. DON B added, after investigating it looked like she needed to go to the bathroom. Note, Offer toileting after meals was previously added to R48's care plan on 8/19/19, over one year prior. Did you get statements from staff as part of your investigation (e.g. the last time R48 was toileted). DON B stated, No. Surveyor asked DON B should that have been done. DON B stated, yes, staff should investigate to determine when R48 was last toileted, last seen, what was R48 doing, what was her mood, anything out of the ordinary, including the environment. Surveyor spoke with DON B regarding R48's fall on 10/30/20. Note, R48 was sent to the ED following this fall where she received 9 sutures and 5 staples to the back of her head. DON B stated R48 was tired, leaned forward, and fell out of her wheelchair while in her room. The immediate intervention indicated on the Incident Report is Resident was laid in bed. Steps to prevent recurrence: Lay R48 down after meals. Note, this intervention was not added to R48's CNA Care Card or care plan. Surveyor asked DON B do you see this intervention on R48's care plan. DON B stated, No, I don't. Surveyor asked DON B, should the intervention have been added to her care plan? DON B stated, It sure should be. Surveyor asked DON B were staff educated after this fall. DON B stated, I have no education on this. Staff were to keep an eye on her and lay her down after meals. DON B added, this would have been after lunch for R48. Staff would have emptied her cath when laying her down. The only way staff would have been toileting her is if she had a bowel movement. Surveyor asked DON B did you obtain statements from staff related to this fall. DON B stated, Nope. Surveyor asked DON B, should you have obtained statements from staff. DON B stated, Yes, I definitely should have. Surveyor asked DON B, do you feel you investigated R48's fall thoroughly. DON B stated, I feel I could have done a lot more, as an IDT (interdisciplinary team) team, we should have put a more appropriate intervention in place. I would have gone with anti-tip bars. Surveyor asked DON B did you recommend that to IDT. DON B stated, No. DON B stated she brought the incident report to IDT meeting the next day and discussed as a team the most appropriate intervention. That RN/MDS F (Registered Nurse/Minimum Data Set) is supposed to update the care plan as we're talking to make sure the appropriate intervention is put in place. DON B added, we should do a better job looking at root cause, interventions, and updating care plans. Surveyor spoke with DON B regarding R48's fall on 11/13/20. DON B stated she expects rounding on R48 every 2 hours if not more frequently. Surveyor asked DON B what was the root cause of R48's fall. DON B stated, R48 was transferring (independently) from one surface to another. Surveyor asked DON B was R48 transferring from her wheelchair. DON B stated she cannot tell. Surveyor asked DON B what was R48 trying to do. DON B stated, R48 was unable to verbalize. Surveyor asked DON B what is the intervention for this fall. DON B stated R48's bed was too high up. The new intervention is bed height appropriate and bed remains in lowest position. Note, there is no documentation of this intervention. Surveyor asked DON B was that intervention added to R48's care plan. DON B stated, No, the care plan wasn't updated since August 2019. Note, no new interventions have been added to R48's care plan since August 2019. Surveyor asked DON B should this intervention be on the care plan. DON B stated yes. Surveyor spoke with DON B regarding R48's fall on 12/21/20. Surveyor asked DON B did R48 fall on 12/21/20. DON B stated, I don't have any incident on that. Note, no incident report was provided to Surveyor for this fall when requested. DON B added, she wasn't here for the fall follow up on this one. DON B stated, I was home and remember them sending her out and there was a bump on her head. Surveyor requested DON B to look into this and follow up with Surveyor. On 1/21/21 at approximately 6:00 PM, RC D provided Surveyor with a copy of a 1 page Incident Investigation for R48. The Date Time and Incident Type were all blank. This was a partial Incident Investigation for R48's fall on 12/21/20. RC D stated to Surveyor that they were not aware of this incident and Investigation Report because the nurse did not enter the Date Time and Incident Type. RC D stated there is only 1 page for this fall (missing page 2/2). RC D stated there are no statements. The report states Description of Incident Statement of observation when resident found: resident found down lying on L (left) side in front of wheelchair. What resident stated regarding fall: R48 was lethargic and not answering questions. Describe why it happened: Behavior prior to fall: baseline for resident, confused. Easily fatigues: Yes call light in reach: was in hallway Safety Equipment in Place: brakes working, nonskid socks on feet Footwear: wearing nonskid socks Assistive device(s) used per care plan: using wheelchair Care plan directive followed: Yes Describe what caused incident: Root cause identified: Patient attempted to get out of wheelchair without assistance and fell . Resident Injury/Outcome: Sent to ED Injury: No apparent injury Describe equipment involved: Wheelchair-resident was previously using her wheelchair. Steps to Prevent Recurrence: Place resident in her room where her call light is available, try to reorient resident. Surveyor spoke with DON B regarding R48's fall on 12/26/20. Surveyor asked DON B can you tell me what happened with this fall. DON B stated, that's the one where they were using the EZ stand and staff lowered R48 to the floor. R48 put her hands in the air while being transferred with the EZ stand. Staff was able to help her down safely. Surveyor asked DON B, was education provided to staff. DON B stated yes, 2 staff at all times for transfers with equipment. That's our safety standard. R48 should be a 2 assist as of 12/26/20. Our policy is 12/26/20 for the EZ stand. DON B added, this is not necessarily 2 people hands on but in case there's a problem. If she was on the COVID unit my guess is she was very weak. Note, R48 is care planned for 1 assist for transfers; R48's care plan was not updated. Surveyor asked if R48's care plan should have been updated with this intervention. DON B stated, yes. On 1/21/21 at 2:36 PM, Surveyor spoke with DON B (Director of Nursing). Surveyor asked DON B is R48 care planned to wear gripper socks. DON B stated, Yes. Surveyor asked when should R48 be wearing gripper socks. DON B stated, I would have them on her at all times. Surveyor shared observation of R48 in bed with bare feet. Surveyor asked DON B should R48 have been wearing gripper socks. DON B stated, yes. Surveyor asked DON B are you aware that if you or other staff have provided risk and benefits to R48 and/or her APOAHC related to R48 self-transferring. DON B stated, not that she is aware. DON B added, I haven't personally. On 1/21/21 at 4:50 PM, Surveyor spoke with RC D. RC D confirmed she contacted the hospital to obtain the report for R48's fall on 12/21/20 per Surveyor's request. RC D stated RN M (Registered Nurse) did not complete the incident report (fall investigation). RC D stated when staff enter an incident report, it notifies other staff and management of the incident. RC D stated we will educate RN M and have her do a late entry. The incident report alerts us that there has been an incident in the facility and the nurse did not do that. RN M is a casual or PRN (as needed) staff member. RC D added, DON B was confused because there was no incident report and she was not aware of the incident. Note, DON B stated they notified her when she was off; DON B was aware of the incident. On 1/14/21 RC D stated she met with DON B and other staff regarding if they are out who is their back up. If somebody needs to read their Nurse Notes and when they come back they need to read their NN and catch up. Morning (AM) duties should be reviewed in stand up meeting. RC D stated, we want them to do this as a team for root cause analysis and put things in place before they leave the meeting. It is important to note, the facility was unaware of this fall and had no follow up, no root cause analysis, and no immediate intervention to ensure R48's safety. The facility's Elopement and Wandering Management policy dated 10/20 states in part: . All instances of elopement attempts will be documented in the Nurse Charting tab .10. All door alarms and magnets will be routinely inspected per facility preventative maintenance policy. The facility Policy Elopement - Missing Resident Response dated 10/20, includes, in part: In the event that a resident is identified as missing, a search for the resident shall be conducted in a systematic manner using all available staff. A resident elopement is defined as the situation where a cognitively impaired resident with impaired safety judgment leaves the facility without staff knowledge. A missing resident is defined as a resident leaving the premises without staff knowledge or not returning at the expected designated time. Protocol: 2. When a resident is identified as missing, the following steps will be initiated: a. immediately notify the charge nurse on duty. b. The nursing supervisor will immediately check the Resident Sign - Out Sheet to determine if the resident has been taken out of the building by a responsible party. c. if the resident has not been signed out, the charge nurse will notify all available staff via overhead page or similar method to come to the nursing station or other centralized announced location at once. d. The charge nurse will assign an employee to physically check each alarmed exit to determine if all alarms are in working order (this may identify the exit the resident used to elope). e. The charge nurse shall initiate a comprehensive search of the facility and grounds by assigning any available staff to specific areas. Assigned staff members will check thoroughly inside the facility for the missing resident. f. Assigned staff members will check outside - walk completely around the perimeter of the facility. g. As soon as the resident search is underway, the charge nurse will immediately notify the administrator. 3. If a thorough search of the facility and grounds does not locate the resident, the following additional steps will be initiated: a. the administrator or designee will notify local law enforcement officials. a. written description and a recent photograph of the resident shall be obtained by the nursing supervisor to give to the police. b. the Director of Nursing or designee will notify resident's legal representative and /or family. c. The Director of Nursing or designee will, notify the attending physician and medical director to inform of missing resident. d. The administrator of designee will, notify corporate management. e. The administrator of designee will, if required by state law, notify the state regulatory agency. f. all staff will continue looking inside and outside the facility. g. When resident is found, notify all involved parties. h. the charge nurse will ensure that a thorough physical assessment is performed on the resident. i. the director of [TRUNCATED]

Based on interview and record review the facility did not ensure Residents maintained acceptable parameters of nutritonal status for 1 of 1 Residents out of a total sample of 10 Residents (R1). R1 had a significant weight loss from March to September 2020. The facility did not receive a new diet order based on speech therapy recommendations, R1 continued to lose weight. This is evidenced by: Facility Policy entitled 'Weight Management,' states in part: .Protocol: .3. Weekly weights are completed for residents with an assessed need, most often residents with poor food/fluid intake, recent weight loss and for residents who otherwise have been indicated by nursing or dietary to require closer monitoring.6. Resident's weight information is reported by the C.N.A to the licensed nurse then recorded in the medical record by the licensed nurse in the ECS vital statistics folder. 7. The licensed nurse will determine if an additional (third) reweight is required and accompany the C.N.A to monitor the process. 8. The licensed nurse notifies the Dietary Director/RD (Registered Dietitian) of residents with a significant/severe weight change. A significant/severe weight change is indicated by any of the following: a. 1 month, significant 5% (percent), severe greater than 5% b. 3 months, significant 7.5%, severe greater than 7.5% c. 6 months, significant 10%, severe greater than 10%.10. The Dietary Director/RD assess each resident with a significant or severe weight change as soon as practicable, makes appropriate recommendations to physicians and updates the residents' plan of care . R1 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 2/6/20 at 3:29 PM R1's weight was 128.8 pounds. On 2/17/20 R1 is indicated as having an order for [REDACTED]. On 2/27/20 at 2:00 PM, R1's 'Medical Nutrition Therapy Note: Re-weight pattern and swallowing update' states in part: This writer was alerted that (R1) has been pocketing her food. This writer spoke with (Director of Rehab.) to set up a screen with speech therapy. Her current weight is 128.8#. This reflects a 6.0% loss in 30d (days). Weight loss could be related to possible swallowing issue. Intervention is to have speech therapy evaluate (R1) to help find food texture or cues to help increase (R1's) intake. On 3/6/20 at 6:22 PM, R1's weight was 124 pounds. On 3/16/20 at 3:44 PM, R1's 'Medical Nutrition Therapy Note: Re-weight pattern' states in part: current weight is 124#. This reflects a nonsignificant 3.1% loss 30d, a 10.8% loss over 90d. (R1) has been consuming her supplement 25-100%. Her meal intakes are typically 50%, but her dinner intakes are poor at 0-15%. Since 2/17, her weight has stayed stable within 122-124# range. Supplement is effective at this time in preventing further weight loss . On 3/17/20 R1's Fax sent by DM D (Dietary Manager) states in part: Situation: current weight is 124#. Background: since 2/17, (R1's) weights have remained stable within 122-124#. Assessment/appearance: supplement intervention remains effective at this time. Request: no action to be taken. This is just a notification. Physician responded ok, on 3/24/20. On 3/25/20 at 3:40 PM, R1's 'Medical Nutrition Therapy Note: Re weight pattern,' states in part: Current weight is 113#. This reflects a 11# loss in one week. Will request re-weight on resident as this change does not seem likely. She has been consuming her supplement 25-100% , with 100% intakes earlier in the day. Meal intakes have been around 50%. Continue to monitor weights and intakes. There is no documentation to indicate in the Nurses notes or Dietary notes that R1's Physician or POA was updated on R1's weight loss at this time. R1's March 2020 Intake Record shows 54 meals being documented out of a total of 93 meals. The other 39 meals are blank. R1's meal intakes are not consistently charted on to show how much R1 is actually consuming each meal for food or fluids. On 4/3/20 at 1:38 PM, R1's weight was 117 pounds. (R1 lost 7 pounds over a month, resulting in a 5.64% weight loss in approximately 30 days.) On 4/10/20 R1's Fax sent by DM D states in part: Situation: Current weight is 117#. This reflects stable 30 day weight and significant 14.6% loss over 90 days.Assessment/Appearance: (R1's) medpass intakes have improved from 25-50% to 100% in the evenings. Anticipate weight to be stable. Request: No action to be taken this is just a notification. Physician responded on 4/13/20 with ok. R1's April 2020 Intake Record shows 34 meals are documented out of 90 meals. The other 56 meals are blank. On 5/6/20 at 7:13 PM, R1's weight was 112.5 pounds. On 5/8/20 at 3:37 PM, R1's 'Medical Nutrition Therapy Note: Re-weight pattern' states in part: current weight is 112.5. This reflects a nonsignificant 3.0% loss over 30d, significant 12.7% loss over 90d and significant 19.1% loss over 180d. She receives a medpass 2.0 supplement BID (twice daily) and consumes 50-100% with most intakes at 100%. Will request increasing supplement. Continue to monitor weights and intakes. On 5/11/20 R1 is indicated as having an order for [REDACTED]. On 5/18/20 at 4:07 PM, R1's 'Medical Nutrition Therapy Note: Re-weight pattern,' states in part: current weight is 111#.continues to receive medpass 2.0 supplement TID. Intakes are 25-100%, with most intakes being 100%. Meal intakes are 25% . On 5/22/20 R1's Fax sent by DM D,states in part: Situation: (R1's) current weight is 111# this reflects significant 9.6% loss 90d, and 20.1% loss 180d.Assessment/Appearance: Takes supplements 100% (med pass 4 oz TID) meal intakes are 0-25% per staff, she is pocketing food on minced-moist diet. Request: will downgrade to puree diet. Physician response on 5/22/20 Ok. On 5/24/20 R1's significant change MDS indicates in Section E that R1 has no behaviors or rejection of cares. Section G indicates that R1 is totally dependent on a 1 person extensive assist with bed mobility and toileting. R1 requires full staff performance with a two person extensive assist for transfers between surfaces. R1 requires supervision/encouragement/cuing with setup help only for eating. Section K indicates R1 holds food in mouth/cheeks or has residual food in mouth after meals and that R1's weight is 111 pounds at this time. Section M indicates that R1 is at risk for pressure injuries and currently does not have any unhealed pressure injuries. On 5/26/20 R1 is indicated as having her diet order changed to Pureed (IDDI level 4) with thin liquids (IDDSI level 0) at this time. (IDDSI is the International Dysphagia Diet Standardization Initiative to standardize labeling of texture-modified foods and thickened liquids.) R1's May 2020 Intake Record shows 35 meals documented out of 93 meals. Those intakes are documented as bites to 50%. The other 58 meals are blank. Intakes are not consistently documented for the month of May to indicate how much R1 is actually consuming for food or fluids. On 6/5/20 at 3:38 PM, R1's weight was 106.5 pounds (R1 experienced another 5.33% weight loss in a month.) On 6/8/20 at 9:48 AM, R1's 'Medical Nutrition Therapy Note: Re-weight pattern' states in part: Current weight is 106#. This reflects a nonsignificant 4.5% loss 30d, significant 13.3% loss 90d and significant 23.7% loss 180d. (R1) has been receiving a medpass 2.0 supplement TID (three times a day) she consumes 25-100%, with most intake being >75% (greater than 75%). Meal intakes are poor with most intakes ranging from refusals - 25%. It appears as though (R1) may be drinking more than eating. Will update tray card to include more beverages like milk/chocolate milk to help with increasing intakes. On 6/8/20 R1's Fax sent by DM D states in part: Situation: current weight is 106# this is nonsignificant 4.5% loss 30 days, 13.3% (significant) loss at 90 days, and significant 23.7% loss 180d. Background: med pass intakes are mostly >75%. Assessment/appearance: meal intakes are poor ranging from refusable to 25% she is drinking liquids. Request: no action to be taken. Tray card updated to include more beverages. Physician response ok, on 6/9/20. There is no evidence to show that R1's family or POA was updated on R1's continued weight loss at this time. R1's June 2020 Intake Record shows 14 meals documented out of 90 meals. Those intake are documented as refused to 25% while the other 76 meals are blank. R1's July 2020 Intake Record shows R1 ate between 25 to 75% for meals. On 7/3/20 at 3:10 PM, R1's weight was 102.4 pounds. On 7/22/20 at 4:03 PM, R1's Progress Notes indicate R1's husband was called regarding R1's favorite foods. No documentation was provided to Surveyor to indicate that DM D, who is also the Registered Dietitian, evaluated or assessed R1's meal intakes or weights between 6/8/20 through 8/14/20. On 7/28/20 R1 develops a new Pressure Injury to her Right ischium. R1's nutritional needs have now increased due to having a pressure injury. On 7/29/20 R1's significant change MDS indicates R1 is severely cognitively impaired, was totally dependent (full staff performance) on 1 person extensive assist with bed mobility, transfers and toileting. R1 needed extensive assist of 1 for eating. Section K indicates that R1 holds food in mouth/cheeks or has residual food in mouth after meal. R1's weight is 102 pounds at this time and is marked as having weight loss of 5% (percent) or more in the last month or loss of 10% or more in the last 6 months without a physician-prescribed weight loss regimen. Section M indicates that R1 is at risk for pressure injuries and currently has unhealed pressure injuries. R1 is indicated as having one stage II pressure injury at this time. R1's August 2020 Intake Record shows R1 ate between bites to 50% mostly, with a few 75% meal intakes and a couple refusals. On 8/5/20 at 12:40 PM, R1's weight was 102 pounds. R1's MAR for August 2020 indicates R1 started on Pro-stat (protein supplement) on 8/5/20 for wound healing. On 8/14/20 R1's Physician order [REDACTED]. On 8/17/20 R1's physician's orders [REDACTED]. Signed by R1's Physician on 8/24/20. On 8/17/20 R1 continues to have a right ischial pressure injury along with two new pressure injuries on her left ischial. R1's nutritional needs are increased again due to having 3 pressure injuries at this time. On 8/20/20 R1's 'Rehab to Facility Communication' form states in part: Speech Therapy Recommendations for nursing . Current function status: pt. (patient) is on IDDSI levels 4 (puree) and 0 (thin) blended together into a drinkable form to maximize intake. 2. Aspiration precautions. 3. Patient/Caregiver goals to improve intake & nutritional status on least restrictive diet. 4. Recommendations/approaches: -pt has best intake when items present per cup. Puree items may be mixed with thin liquids into drinkable form to maximize intake. Observe a swallow with each bite/sip before presenting more. 5. Therapist Signature (ST J (Speech Therapist)) Date: 8/20/20 . On 8/21/20 at 11:13 AM, R1's weight was 95.0 pounds. On 8/23/20 at 11:09 PM, R1's weight was 101 pounds. On 8/24/20 R1's Fax form filled out by DM D states in part: Current weight is 101# This reflects stable over 30 days, significant 9.0% loss over 90 days, and significant 17.8% loss over 180 days .meal intakes range from bites - 75% with 1 refusal in the last 7 days. Staff report pocketing with puree diet, but state she is drinking well. Request: could we initiate a liquidized diet (IDDSI level 3)? On 8/24/20 at 2:18 PM, R1's 'Medical Nutrition Therapy Note: Re-weight pattern' states in part: Current weight is 101#. This reflects stable over 30 days, a significant 9.0% loss over 90 days, and significant 17.8% loss over 180d. (R1) has intakes that range from bites to 75% with 1 documented meal refusal in the last 7 days. She receives a med pass supplement TID and has intakes ranging from 50-100%. Most intakes are 100%. Staff report she has had increased pocketing of her pureed food, but has been drinking her liquids well. Speech therapy was consulted and was in agreement with downgrading to a liquidized diet, IDDSI level 3. Will request order from MD. Continue to encourage intakes and assist with meals as needed. There is no documentation to show this fax was followed up on timely by facility staff or acknowledgement or a declination by the Physician. The Speech Therapist recommendation was on 8/20/20. Per documentation the DM D did not address this recommendation until 8/24/20. On 8/27/20 at 11:09 PM R1's weight was 93.2 pounds. On 8/31/20 R1's 'Rehab to Facility Communication' form states in part: Speech Therapy .recommendation to Nursing. 1. Current Functional Status: pt's on puree (IDDSI level 4) (with) ok to blend puree solids (with) nectar (IDDSI level 2) into drinkable form. 2. Precautions: Aspiration precautions. 3. Patient/caregiver goals: Maximize intake on least restrictive diet. 4. Recommendations/approaches: pt has best intake when items presented per cup. Puree may be blended with liquids into drinkable form to maximize intake. Observe a swallow with each bite/sip before presenting more. 5. Therapist signature (ST J's signature) Date: 8/31/20 . On 8/31/20 R1's Physician Telephone Order sheet, (no physician signature) states in part: 1. Change liquid consistency to nectar thick (IDDSI level 2). May blend puree solids (with) liquids into drinkable form at nectar thick consistency. 2. (discontinue) speech therapy (after) 9/2/20.(signed by ST J). There is no indication on Surveyors copy this order was actually faxed to the Physician or when it was faxed. There is no documentation to show that DM C or any other staff member followed up via fax or phone call to R1's Physician regarding R1s Speech Therapy Recommendations or faxes. R1 continues to lose weight. R1's September 2020 Intake Record shows R1 ate most days between 0 to 25%. On 9/2/20 at 1:53 PM, R1's weight was 86 pounds. On 9/4/20 at 2:35PM, R1's weight was 88.4 pounds. On 9/9/20 at 2:16 PM, R1's weight was 83.4 pounds. There are no further weights documented for R1 in the documentation provided to Surveyor. R1 has gone from 102 pounds to 83.4 pounds in a little over a month resulting in a 18.23% weight loss. R1's liquidized diet recommendation order still has not been obtained even though DM C and ST J indicated R1 drinks well. On 9/11/20 at 3:13 PM R1's 'Medical Nutrition Therapy Note: Re-weight pattern' states in part: Current weight is 83.4#. This reflects a significant 18.2% loss over 30d, significant 17.3% loss over 90d and significant 32.7% loss over 180d. She is receiving a med pass supplement TID and consuming 50-100% with one documented refusal in the last 7 days. Meal intakes range from 0-100% with most intakes being less than 50%. Speech therapy worked with (R1) and requested she be on an IDDSI level 2 nectar consistency for liquids and continue liquidized diet. Still awaiting order confirmation from MD. Will re-send request. Continue to monitor weights and intakes. On 9/11/20 R1's Fax sent by DM D states in part: .Current weight Is 83.4#. This reflects a significant 18.2% loss over 30 (days), 17.3% loss over 90 days and 32.7% loss over 180 (days). Meal intakes vary 0-100%, most <50% supplement intakes mostly 100% TID (three times a day) . (change) diet texture to IDDSI level 3 liquidized & IDDSI level 2 nectar per SLP recs. There is no documentation to show what date or time this form was sent. There is no documentation to show this fax was followed up on timely or that this recommendation was ever received by the Physician or if the recommendation was declined. There is no evidence that the facility tried to increase R1's supplements above three times a day. On 9/16/20 around 9:15 PM R1 passed away. On 9/30/20 at 7:50 AM, Surveyor interviewed DM D regarding R1. DM D indicated staff never received a faxed order back for a liquid diet. DM D indicated that weights and meal intakes are monitored. DM D indicated intakes are monitored after every meal by CNAs. DM D indicated that CNAs write down meal intakes in the books and DM D does weekly reviews of weights and intakes. DM D indicated R1's supplement was changed to three times a day due to R1 having wounds. DM D stated no indicating additional supplements were not offered if R1 was not eating. (R1 has had an order for [REDACTED]. On 9/30/20 at 10:41 AM, Surveyor interviewed ST J (Speech Therapist) regarding R1. ST J indicated R1 was referred to her due to not eating well. ST J indicated R1 was assessed to be taking liquids better and making pureed foods into liquid with staff assist. ST J indicated she wrote a recommendation for staff and educated staff on how to encourage intakes with R1 and R1 was to get up for meals and snacks or be upright in bed. ST J indicated DM C was to get R1 a liquidized diet order. ST J indicated she does not look at the intake records. ST J indicated DM C would be the one to look at R1's intake records. On 9/30/20 at 1:58 PM, Surveyor interviewed RN F regarding R1. RN F indicated R1 would be up for meals in her wheelchair and staff would feed her. RN F indicated R1's intake wasn't the best and staff would mix ice cream in with foods R1 liked. RN F indicated R1 would drink her supplements and R1 liked the supplements. RN F indicated the last few weeks R1 really declined. On 9/30/20 at 3:13 PM, Surveyor interviewed DM D regarding R1. DM D indicated as soon as possible, as being an appropriate time frame to receive a diet change order. DM D indicated she is not able to call the Physician for a diet change order. DM D indicated she has no documentation to show when she faxed the Physician other than the date she wrote on the fax forms. (There is no evidence that any facility staff member followed up on either of the Speech Therapists recommendations or requests for diet change orders for R1 even though she was experiencing a significant amount of weight loss.) On 10/2/20 at 3:25 PM, Surveyor received and reviewed additional information from the NHA (Nursing Home Administrator) regarding R1. This additional information did not impact the citation as written above. On 10/2/20 Additional information was received from NHA A regarding ST J's order request on 8/31/20. The additional information indicates the request was not faxed until 9/4/20. This is a delay of approximately 4 to 5 days. On 10/2/20 this order is now signed on 10/1/20 by a Physician that is not R1's Physician. Please note R1 passed away on 9/16/20.

Based on interview and record review the facility did not ensure Residents received care consistent with professional standards of practice to promote healing and prevent new ulcers from developing for 1 of 1 Residents (R) out of a total sample of 10 Residents (R1). R1 was at risk for Pressure Injuries. R1 developed pressure injuries (PI) including a Stage III PI. R1 had a foam mattress on her bed, sat up in her recliner without a cushion and experienced significant weight loss placing her at a higher risk for PI development. Interventions to prevent PI's were not put into place timely and the facility failed to complete a root cause analysis for R1's Pressure Injuries. This is evidenced by: Facility Policy entitled 'Skin Care Management' revised 11/19 states in part: Purpose: It is the policy of this nursing home to provide skin care to residents that includes assessment, prevention of skin break down and management of pressure injury and other skin integrity concerns. Protocol: 10. The NPUAP/EPUAP/PPPIA Prevention and treatment of [REDACTED]. The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White paper, dated 2009, states in part: .Nutrition and Pressure Ulcers, although limited evidence - based research is available, general consensus indicates that nutrition is an important aspect of a comprehensive care plan for prevention and treatment of [REDACTED]. Adequate calories, protein, fluids, vitamins, and minerals are required by the body for maintaining tissue integrity and preventing tissue breakdown .compromised nutritional status such as unintentional weight loss, undernutrition, protein energy malnutrition (PEM), and dehydration deficits are known risk factors for pressure ulcer development. Other nutrition - related risk factors associated with increased risk of pressure ulcers include low body mass index (BMI), reduced food intake, and impaired ability to eat independently .poor outcomes are associated with undernutrition including the risk of morbidity and mortality, hence the need to quickly identify and treat undernutrition.The type and amount of food/fluid ingested daily should be reviewed periodically to ensure the individual actually ingests enough calories based on estimated needs. It is also important to examine the reasons for the intake being decreased. Oral nutritional supplements, enhanced foods, and food fortifiers can be used to combat unintended weight loss and undernutrition . Per the National Pressure Injury Advisory Panel (NPIAP), Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Per the NPIAP, Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. 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, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Per the NPIAP, Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) 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 and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Per the NPIAP, Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss 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 (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Per the NPIAP, Deep Tissue Pressure 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 NAME] 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). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. R1 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 2/24/20 R1's Quarterly MDS (minimum data set) indicates R1 has a BIMS (Brief interview of mental status) of a 02 out of 15 indicating R1 was severely cognitively impaired. Section E indicates R1 has no behaviors or had not rejected cares. Section G indicates that R1 is totally dependent on physical assist of 1 for bed mobility, transfers, and toileting. R1 eats independently with setup. Section K indicates that R1 holds food in her mouth/cheeks or has residual food in mouth after meals and complains of difficulty or pain with swallowing. R1's weight is 123 pounds. On 3/16/20 R1's Care Plan states, in part: Special Care Remarks: .Assist to recliner between meals. There is no indication on R1's Care Plan if R1 had a cushion in her recliner chair. (It's important to note that this intervention of assisting R1 to her recliner was in place until R1 passed away on 9/16/20.) On 3/16/20 R1's Braden Scale score is 13, indicating R1 was at moderate risk for pressure injury development. On 3/6/20 at 6:22 PM, R1's weight was 124 pounds. On 4/3/20 at 1:38 PM, R1's weight was 117 pounds. (R1 lost 5.64% in approx. 1 month.) On 5/6/20 at 7:13 PM, R1's weight was 112.5 pounds. (This is a 12.34% weight loss since March or 3.8% in one month.) R1 Previously had an unstageable PI to her heel in January (2020), which is indicated as resolved in May of 2020. On 5/24/20 R1's significant change MDS indicates in Section E that R1 has no behaviors or rejection of cares. Section G indicates that R1 is totally dependent on a 1 person extensive assist with bed mobility and toileting. R1 requires full staff performance with a two person extensive assist for transfers between surfaces. R1 requires supervision/encouragement/cuing with setup help only for eating. Section K indicates R1 holds food in mouth/cheeks or has residual food in mouth after meals and that R1's weight is 111 pounds at this time. Section M indicates that R1 is at risk for pressure injuries and currently does not have any unhealed pressure injuries. On 6/5/20 at 3:38 PM, R1's weight was 106.5 pounds (Showing R1 has a 5.33% weight loss in 30 days, 8.79% weight loss in 60 days or 14.11% in 90 days.) On 6/8/20 R1's Braden Scale score was 13, indicating R1 was at moderate risk for development of pressure injuries. On 6/17/20 R1's Care Plan states in part: Turning/Repositioning: Reposition every 2 hours, offload heels, and boots on at all times. (Discontinued on 7/28/20) On 7/3/20 at 3:10 PM, R1's weight was 102.4 pounds. (R1 has lost 12.47% of her weight since 4/3/20.) R1's weight loss from March to July 2020 put her at greater risk for pressure injury development. There is no evidence staff assessed this increased risk and made changes to R1's skin care plan. There is no evidence that R1 has a cushion in her recliner. On 7/28/20 R1's 'Skin Care Flow Sheet' indicates R1 is discovered to have a new in-house acquired pressure injury to her Right ischium. R1's wound is indicated as being a stage II measuring (length by width by depth) 1.1cm (centimeters) by 0.9cm (no depth measurement) with a red wound base and a scant amount of serosanguineous drainage. Physician was notified. Treatment is indicated as calcium alginate, [MEDICATION NAME] daily. There is no root-cause analysis documented or indicated for R1's Right ischium wound. On 7/28/20 at 2:50 AM, R1's Nursing Progress Notes state in part: Fax sent to: (physician name) regarding: Skin treatment. Result: new orders received and noted 07/28/2020 - 1) skin treatment: PI stage II right ischial - cleanse, pat dry, apply [MEDICATION NAME] skin prep to peri-wound (surrounding skin) and let dry. Place calcium alginate on wound bed and cover with [MEDICATION NAME] foam dressing daily . On 7/28/20 R1's Care Plan, indicates Supportive devices, wheel chair as needed (must have foot pedals) wheelchair cushion, geo mattress. (Discontinued date of 7/29/20) Turning/Repositioning: Reposition every 1 hour, offload heels, and boot on at all times. Special Care Remarks: .Assist to recliner between meals. (Start date 3/16/20) There is no indication of R1 having a wheelchair cushion on R1's care plan prior to 7/28/20. There is no indication that R1's supplements were evaluated or increased at this time to ensure adequate nutrition as her nutritional needs have increased at this time. Per interview with LPN C on 9/30/20 around 2:00 PM LPN C indicated that R1's cushion was a gel cushion. Gel-T cushion Manufacturer information indicates this chair cushion is for users at moderate risk for pressure ulcers/pressure injuries. There is no evidence from the manufacturer that this cushion is suitable to be used once PI's develop. On 7/28/20 R1's Braden Scale score is 14, indicating R1 is at moderate risk for Pressure injury development. On 7/29/20 at 10:11 AM, R1's Nursing Progress Notes state in part: Call placed to: family/guardian, (name) regarding: skin condition/treatment. Result: POA notified of PI stage II to right ischial and interventions in place . On 7/29/20 R1's Care Plan, states in part: Wheelchair as needed (must have foot pedals) wheelchair cushion, air mattress. On 7/29/20 R1's significant change MDS indicates R1 is severely cognitively impaired, was totally dependent (full staff performance) on 1 person extensive assist with bed mobility, transfers and toileting. R1 needed extensive assist of 1 for eating. Section K indicates that R1 holds food in mouth/cheeks or has residual food in mouth after meal. R1's weight is 102 pounds at this time and is marked as having weight loss of 5% (percent) or more in the last month or loss of 10% or more in the last 6 months without a physician-prescribed weight loss regimen. Section M indicates that R1 is at risk for pressure injuries and currently has unhealed pressure injuries. R1 is indicated as having one stage II pressure injury at this time. On 8/4/20 R1's Right Ischium 'Skin Care Flow Sheet' indicates R1's wound is now a stage III pressure injury measuring 2cm by 2cm with the wound bed having 25% slough and 75% red tissue. This area is indicated as worsened. Treatment indicated as calcium alginate and [MEDICATION NAME] foam. On 8/5/20 at 12:40 PM, R1's weight was 102 pounds. On 8/5/20 R1's Care Plan, stated in part: Turning/Repositioning: Reposition every 1 hour with use of slip sheet, offload heels and boots on at all times. (Discontinued 8/28/20) (These care plan changes occurred after R1's wound had already worsened.) On 8/5/20 R1's Right Ischium 'Skin Care Flow Sheet' indicates Stage III Pressure injury measuring 2.2cm by 2.3cm by <0.1cm (less than 0.1cm). Wound bed is 25% slough and 75% red tissue with moderate serosanguineous drainage. R1's wound is indicated as worsening and the Physician being notified. Treatment indicated as medi-honey, calcium alginate and [MEDICATION NAME]. On 8/5/20 at 4:15 PM, R1's Nursing Progress Notes state in part: Fax sent to: (Physician name) regarding: skin treatment/status Result: new orders received and noted 08/05/2020- PI stage III right ischial worsening. (2.2cm x 2.3cm x <0.1cm) 1) skin treatment: PI stage III-right ischial-cleanse, pat dry, apply [MEDICATION NAME] skin prep to peri-wound and let dry. Apply medi-honey to wound bed, place calcium alginate on wound bed, and cover with [MEDICATION NAME] foam dressing daily. 2) Pro-stat liquid 30ml BID (twice daily) (for wound)-promote healing of PI Stage III right ischial. On 8/12/20 R1's Right Ischium 'Skin Care Flow Sheet' indicates Stage III pressure injury measuring 1.7cm by 1.9cm by <0.1cm. Wound bed is 10% slough and 90% red tissue. R1's wound is indicated as improved. Treatment indicated as same as above. On 8/13/20 R1's Care Plan states in part: Supportive devices: Wheelchair as needed (must have foot pedals) span American geo wheelchair cushion, pressure guard easy air mattress. (Discontinued on 8/17/20) (R1's wheel chair cushion was not changed until 8/13/20 after R1's Right ischial wound had already developed and had worsened to a Stage III on 8/5/20.) On 8/14/20 R1's Braden Scale is a 9, indicating R1 is at very high risk for developing pressure injuries. On 8/17/20 R1's Left Ischium (top) 'Skin Care Flow Sheet,' indicates a new stage I facility acquired pressure injury measuring 2.2cm by 2.7cm with a deep purple wound bed. Treatment indicated as monitor. On 8/17/20 R1's Left Ischium (bottom) 'Skin Care Flow Sheet,' indicates new stage I facility acquired pressure injury measuring 1.9cm by 2.9cm with a deep purple wound base. Treatment indicated as monitor. On 8/17/20 R1's Care Plan, states in part: Supportive devices: wheelchair as needed (must have foot pedals), Span America Geo wheelchair cushion, padding to sides of wheelchair for protection, pressure guard easy air mattress. There is no root-cause analysis documented or indicated for R1's left ischium wounds. On 8/19/20 R1's Right Ischium 'Skin Care Flow Sheet' indicates Stage III pressure injury measuring 2.4cm by 1.9cm by 0.1cm. Wound bed is indicated as being 50% yellow slough and 50% red tissue with moderate serosanguineous drainage. R1's wound is indicated as worsening and that the Physician was updated. Treatment is indicated as same as above R1's wound is now covered with 50% slough, indicating 50% of the wound bed is unable to be visualized for depth, indicating that R1's wound is now an Unstageable PI. On 8/19/20 R1's Left Ischium (top) 'Skin Care Flow Sheet,' indicates Stage I PI measuring 2.2cm by 2.4cm with a deep purple wound bed. On 8/19/20 R1's Left Ischium (bottom) 'Skin Care Flow Sheet' indicates Stage I PI measuring 1.7cm by 2.5cm with a deep purple wound bed. On 8/21/20 at 11:13 AM, R1's weight was 95.0 pounds. On 8/23/20 at 11:09 PM, R1's weight was 101 pounds. On 8/26/20 R1's Right Ischium 'Skin Care Flow Sheet' indicates Stage III pressure injury measuring 2.7cm by 2.1cm by 0.1cm. Wound bed is indicated as being 10% black eschar, 40% yellow slough and 50% red tissue with moderate serosanguineous drainage. Wound is indicated as worsening and Physician updated. Treatment is indicated as same as above. On 8/26/20 R1's Left Ischium (top) 'Skin Care Flow Sheet' indicates Stage I PI measuring 2.7cm by 2.9cm with a red wound bed. Indicated as worsening. Treatment indicated as hydrocelluar foam. On 8/26/20 R1's Left Ischium (bottom) 'Skin Care Flow Sheet,' indicates DTI (Deep Tissue Injury) measuring 1.4cm by 2.5cm with a deep purple wound bed. Treatment indicated as monitor. On 8/27/20 at 11:09 PM R1's weight was 93.2 pounds. R1 continues to lose weight as her skin continues to deteriorate. On 8/28/20 at 4:25 PM, R1's Nurses Note states in part: POA called by writer at 0955 to discuss resident noted decline in status.POA did request that resident be placed on comfort measures/cares due to end of life.(Physician Name) gave T.O (telephone order) for comfort measures/end of life care . On 9/2/20 R1's Right Ischium 'Skin Care Flow Sheet' indicates Stage III pressure injury measuring 3.1cm by 2.4cm by 0.1cm. Wound bed is indicated as 40% black eschar and 60% red tissue. Wound is indicated as worsening-comfort care(s). Treatment is indicated as same as above. On 9/2/20 R1's Left Ischium (top) 'Skin Care Flow Sheet' indicates Stage I PI measuring 2.6cm by 2.4cm (no depth measured) with a wound bed of 20% black eschar and 80% red tissue. Indicated as worsening - comfort care(s), and treatment same as above. On 9/2/20 R1's Left Ischium (bottom) 'Skin Care Flow Sheet' indicates DTI measuring 1.1cm by 2.2cm with a deep purple wound bed. On 9/4/20 R1's Care Plan states in part: Turning/Repositioning: Assist of 2 - reposition every 1 hour with use of slip sheet, offload heels, and boots on at all times. Special care remarks: . Assist to recliner between meals. On 9/4/20 R1's Braden Scale score is a 9, which indicates R1 is at very high risk for pressure injury development. On 9/9/20 at 2:16 PM, R1's weight was 83.4 pounds. (From 8/20 to 8/31/20 Speech therapy made a recommendation for diet changes twice and neither recommendation has been written as an order, or followed up on while R1 continued to lose weight and her nutritional needs remain elevated due to multiple Pressure injuries.) On 9/9/20 R1's Right Ischium 'Skin Care Flow Sheet' indicates Stage III pressure injury measuring 3.1cm by 3.9cm by 0.1cm. Wound bed is indicated as 90% black eschar and 10% yellow slough. Wound is indicated as worsening - comfort care(s) and treatment of [REDACTED]. On 9/9/20 R1's Left Ischium (top) 'Skin Care Flow Sheet' indicates Stage III PI measuring 4.2cm by 3.7cm. Wound bed is indicated as 50% black eschar, 30% yellow slough and 20% (unknown tissue type). Wound is indicated as worsening - comfort care(s). Treatment is indicated as medi-honey, calcium alginate and [MEDICATION NAME]. On 9/9/20 R1's Fax indicates begin skin treatment to PI stage III to left ischium (top) cleanse, pat dry, apply skin prep to peri-wound and let dry. Apply medi-honey to wound bed, place calcium alginate on wound bed, and cover with [MEDICATION NAME] foam dressing daily. (Physician signature on 9/10/20) On 9/9/20 R1's Left Ischium (bottom) 'Skin Care Flow Sheet' indicates DTI measuring 0.9cm by 1.9cm with a deep purple wound base. On 9/16/20 R1's Right Ischium 'Skin Care Flow Sheet, indicates Stage III Pressure Injury measuring 3.6cm by 4.1cm by 0.1cm. Wound bed is indicated as 90% black eschar and 10% yellow slough. Wound is indicated as worsening - comfort care(s), and R1's treatment is indicated as same as above. On 9/16/20 R1's Left Ischium (top) 'Skin Care Flow Sheet' indicates Stage III PI measuring 4.4cm by 4.1cm. Wound bed is indicated as 80% eschar and 20% yellow slough. Wound is indicated as worsening - comfort care(s). On 9/16/20 R1's Left Ischium (bottom) 'Skin Care Flow Sheet' indicates DTI measuring 0.9 cm by 1.9cm with a deep purple wound base. R1 passed away in the evening on 9/16/20. On 9/30/20 at 7:05 AM, Surveyor interviewed CNA G (Certified Nursing Assistant) regarding R1. CNA G indicated that R1 used to get up and eat with her husband but once COVID-19 started R1 didn't want to eat a lot. CNA G indicated that R1 was up every day and staff would feed her. CNA G indicated she would offer R1 coffee and toast prior to breakfast and give bites of ice-cream during meals. CNA G indicated R1 would get up for breakfast and then would be up for a while then R1 would be put in her recliner to watch a movie, then would get up for lunch and would lay down after lunch. CNA G indicated R1 had a cushion in her wheelchair. CNA G indicated R1 did not have a chair cushion in her recliner. CNA G indicated R1's recliner was a regular leather recliner with a manual lever on the side. CNA G indicated staff would try to reposition her every two hours, and near the end she would be repositioned more and would only get up for a couple hours and then into the recliner after breakfast. CNA G indicated during the last week prior to R1's passing, R1 no longer got up. On 9/30/20 at 8:52 AM, Surveyor interviewed LPN C (Licensed Practical Nurse) and DON B (Director of Nursing) regarding R1's wounds. LPN C indicated R1's wound on her Right ischial started on 7/28/20 and a treatment was initiated. LPN C indicated R1's Braden scale on 7/28/20 had a score of 10. LPN C indicated R1's family was notified of her wounds on 7/29/20. LPN C indicated on 8/5/20 R1's wounds were measured and had worsened and LPN C changed R1's treatment orders and started R1 on Prostat on 8/5/20. LPN C indicated on 8/17/20 R1 had two new wounds to her left ischium both were stage I's. LPN C indicated on 8/17/20 R1's care plan was updated to include a geo span wheelchair cushion, as she had previously had a gel cushion. LPN C indicated they also added padding to the sides of R1's wheelchair for protection and R1 had already had a pressure guard air mattress placed on 7/29/20, as R1 had a geo mattress prior to 7/29/20. LPN C indicated that R1 was on an every 1 hour repositioning schedule, had pressure relief boots and pillows between R1's legs. LPN C indicated on 8/28/20 R1's care plan indicated to reposition every hour, to use a slip sheet for repositioning, boots and to off load heels. LPN C indicated R1 was changed to a two person assist for repositioning instead of one on 9/2/20. LPN C indicated on 8/28/20 R1's POA chose for R1 to be on comfort care/end of life measures. LPN C indicated R1 was seen on Physician rounds and the Physician did not look at R1's wounds. LPN C indicated that R1 was on Prostat and Med pass supplements. LPN C indicated R1's wounds went from a stage III to an Unstageable on 8/26/20 due to unable to see tissue, as wound bed was covered with slough or eschar. LPN C indicated the facility does not have a root cause analysis for any of R1's pressure injuries. LPN C stated yes indicating that someone with a history of PI's is at a greater risk for skin breakdown. LPN C indicated R1 did not have a cushion in her recliner. LPN C indicated when she saw R1 she would be in bed laying on her side. LPN C indicated R1 used her recliner prior to skin break down. (Manufacturer information for R1's cushion and mattress provided on 9/30/20 at approximately 2:00 PM by LPN C indicating R1 had a gel cushion in her wheelchair and geo mattress prior to an air mattress.) On 9/30/20 at 1:58 PM, Surveyor interviewed RN F (Registered Nurse) regarding R1. RN F indicated R1 would get up into her wheelchair and sit by the table and staff would feed her. RN F indicated staff would put R1 in her recliner to watch movies. RN F indicated R1 sat in her recliner before and after R1's wounds developed. RN F indicated she can't remember seeing a cushion in R1's recliner. RN F indicated over the last few weeks R1 really declined. On 9/30/20 at 2:21 PM, Surveyor interviewed MCU I (Memory Care Unit Director) regarding R1. MCU I indicated R1's recliner use would alternate between morning and afternoons. MCU I indicated R1 would lay down after meals as well. MCU I indicated R1 used her recliner almost daily up until about the last two weeks and, when R1 was closer to end of life, R1 laid in her bed. MCU I indicated she was unable to recall if R1 had a chair cushion in the recliner. On 9/30/20 at 2:30 PM, Surveyor interviewed CNA H regarding R1. CNA H indicated R1 would get up in the morning for meals then would be put into her recliner or bed. CNA H indicated R1 would use her recliner almost daily to watch a movie. On 10/2/20 at 3:25 PM, Surveyor received and reviewed additional information from the NHA (Nursing Home Administrator) regarding R1 this additional information did not impact the findings above.

Based on observation, interview, and record review, the facility failed to prevent abuse sexual abuse to residents R113 and abuse to R33, which has the potential to affect all 18 residents on the MCU (Memory Care Unit). R22 currently resides on the MCU and is kissing multiple women and putting his hand up R113's shirt groping her while she tried resisting. R22 was the subject of an immediate jeopardy citation on 3/7/19 because of his sexually aggressive behavior toward R113 and other female residents. On 3/7/19 after R22 was observed kissing R113, Surveyor interviewed R113. R113 was upset that R22 kissed her and stated to Surveyor, He should shut up and stay away! R113 stated, I don't like that! R113 further stated, I didn't know what was going on. Surveyor asked R113 do you feel safe. R113 stated, I didn't. Despite R113's cognitive deficits, she clearly expressed her shock and anger as a result of R22's unwanted sexual contact. R22 kissed R113 on the mouth on multiple occasions, including 3/7/19, 12/31/19 and on 1/13/20, R22 not only kissed R113, but cornered her in a room with his left arm around her neck and his right hand inside her shirt groping her while she tried resisting. The facility failed to do the following: 1. The facility was not providing a proactive solution (1:1 or line of sight monitoring) to prevent further abuse from occurring. 2. On 12/15/19 when R22 was observed kissing R23, another female resident, the facility did not update R22's care plan with a more proactive solution to prevent further sexual abuse. Given that R22's behavior was changing, and given his history, immediate action needed to be taken to protect female residents on the MCU. 3. On 12/31/19 when R22 was observed kissing R113, the facility did not report the incident to the state agency and authorities, did not investigate, and did not update R22's care plan with a more proactive solution to prevent further sexual abuse. 4. When staff became aware that R22 was becoming more intrusive and aggressive and perseverating on sex, staff did not modify the care plan with measure that more proactively protected the residents. As a result, a third incident of sexual abuse involving R113 occurred on 1/13/20. The care plan approach to monitor interactions with peers to ensure appropriate directs staff to intervene, but it does not prevent inappropriate interaction. 5. On 1/13/20 when R22 was observed kissing and groping R113, the facility did not conduct a through investigation. The facility did not attempt to interview residents on MCU that are interviewable nor did they interview other staff. The facility failed to keep their most vulnerable residents safe. Using the concept of a reasonable person, women and men don't want to be touched by strangers and would feel threatened, unsafe, and vulnerable if unable to defend themselves from unwanted sexual advances. The facility has repeatedly stated to Surveyors that they do not provide 1:1 supervision or line of sight to protect residents. The facility's failure to keep R113 free from sexual abuse created a finding of Immediate Jeopardy (IJ) beginning on 12/31/19. On 2/10/20 at 3:25 PM, NHA A (Nursing Home Administrator) was informed of the IJ. The IJ was removed on 2/11/20. The deficient practice continues at a scope/severity level of E (potential for more than minimal harm/pattern) as the facility continues to implement its removal plan and as evidenced by the following: Evidenced by The facility policy, Resident Safety Abuse Policy, with a revised date of 9/17 (2), indicates: Sexual abuse is non-consensual sexual contact of any type with a resident. Determination of the resident's ability to consent must be determined. The most widely accepted criteria are: (1) knowledge of relevant information, including risks and benefits, (2) understanding or rational reasoning that reveals a decision that is consistent with the individual's values (competence) and (3) voluntariness (a stated choice without coercion). if the resident has the ability to consent and their representative disagrees about the resident engaging in sexual activity, the facility must honor the resident's wishes. i. Sexual abuse includes but is not limited to: 1. Unwanted intimate touching of any kind especially breasts or perineal area 2. All types of sexual assault or battery, such as rape, sodomy, and coerced nudity 3. Forced observation of masturbation and/or pornography and 4. Taking sexually explicit photographs and/or audio recordings of a resident and maintaining and/or distributing them. 5. On-going Education: In-service programs shall be presented at new employee orientation, at least monthly thereafter and ongoing as needed, which will encompass: i. Prevention, identification, intervention, and reporting of situations in which abuse or mistreatment are likely to occur. ii. Characteristics of the resident population including but not limited to: 1. Residents with a history of aggressive behaviors. 2. Residents who have behaviors which might precipitate resident-to-resident abuse of any kind. 4. Residents who have behaviors related to psychological or medical problems iii. Training in appropriate interventions to deal with aggressive and/or inappropriate behaviors or reactions of residents, dementia management, care of the cognitively impaired resident, and resident abuse prevention. 9. Procedure for investigation a. All alleged violations will be thoroughly investigated and all investigations are conducted by or coordinated through facility administration. d. The supervisor will ensure that the resident(s) is/are protected from further potential abuse, neglect, exploitation or mistreatment while the investigation is in progress. f. The residents' attending physician, facility medical director, corporate management and family will be notified as soon as possible (See Physician Notification/Consultation Parameters Policy and Change in Resident Condition/Status: Resident, Physician and Family/Legal Representative Notification/Consultation Policy). According to Wisconsin Case Law the following are guidelines for determining a person's ability to consent to sex: 1. The person understands the distinctively sexual nature of the conduct .the acts have a special status as sexual. 2. The person understands that their body is private and that they have the right to refuse. 3. The person understands there may be health risks associated with the sexual act. 4. The person understands there may be negative societal response to the conduct. According to the State Operations Manual (SOM) sexual abuse is defined, in part: as non-consensual sexual contact of any type with a resident, as defined at 42 CFR 483.5. Sexual abuse includes, but is not limited to unwanted intimate touching of any kind especially of breasts or perineal area. R22 is a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. R22's BIMS (Brief Interview for Mental Status) on 11/14/19 is 3 (Severe Cognitive Impairment) and he has a Legal Guardian. R22 ambulates and transfers independently. R113 is an [AGE] year old female admitted [DATE] with a diagnose of dementia without behavioral disturbance. R113's BIMS on 11/8/19 is 2 (Severe Cognitive Impairment) and she has an Activated Power of Attorney for Health Care. R113 ambulates and transfers independently. Due to both resident's severe cognitive impairment, neither resident has the ability to consent to a sexual relationship. The facility also did not complete any assessment regarding the resident's ability to consent. R22's CNA Assignment Sheet, dated 2/7/20, states, in part: that R13 transfers and ambulates independently without an assistive device. Toileting: wears large brief, is incontinent and must be toileted every 2 hours and PRN (as needed), provide per care after each incontinent episode. If he is not soiled encourage to sit on toilet every 2 hours. Special Care Remarks: .Likes to sit and visit with peers over coffee and cookies. Does wander into others rooms. R11 sometimes chooses to sleep in common areas in chairs or recliners. Encourage R22 to sleep in his bed in his room. If he chooses to fall asleep in a common area, redirect him to sleep in his bed in his room. Need assist of 1 staff with ADL's on am and pm shift Offer cueing as needed. R22 likes to sit outside when the weather is nice and must be accompanied by staff at all times. Redirect R22 if he begins to enter peers personal space. Approach calmly and redirect gently, does not like to be told what to do. Sits in lounge area in special chair. offer simple tasks. R22 will approach staff pull at his pants, offer diversion, snacks, privacy, toileting. Encourage R22 to eat meals in dining area and spend time in social area or room when he has finished his meal. Does not like to be told what to do by peers. Use a gentle approach when directing R22. Engage in activity. Encourage R22 to lay in bed if he is sleeping in his chair. Attempt to keep R22 active and awake during the day to get more sleep at NOC (night) He does have medication change to assist in sleep hygiene. ACTIVITY: sitting outside when the weather is nice, television, car magazines, visiting. Needs to stay an arms length distance away from female peers. R22's Care Plan, Alteration in Thought Processes, and mood/behavior changes, dated 2/21/19 (discontinued 11/7/19), Related to: Cognitive impairment, depression, anxiety, [MEDICAL CONDITION]. Manifested By: Difficulty with decision making, restlessness, fluctuating awareness. Approach .Has periods of time when he may be sexual in nature with his words and actions. Redirect behavior and encourage to participate in activities. Goal: Will have less than 8 episodes of negative statements a month, will have no physically aggressive episodes, will have no adverse effects related to medication regimen. Goal Time: 2/28/19. The Care Plan (above) was discontinued on 11/7/19 and updated to the following: Alteration in Thought processes, and mood/behavior changes Physical Agression (sic). Note, Physical Agression was added to the Care Plan on 11/7/19. Related to: Cognitive Impairment, depression, anxiety, [MEDICAL CONDITION]. Manifested by: Difficulty with decision making, Restlessness, Fluctuating awareness, Physical agression (sic). Goal: Will have less than 8 episodes of negative statements a month, will have no physically aggressive episodes, will have no adverse effects related to medication regimen. Goal time: 2/7/20 Three months On 3/7/19, R22 was the subject of an immediate jeopardy citation because of his sexually aggressive behavior toward female residents. Historically the facility has monitored R22 for the following behaviors: 11/8/17 Added - Negative statements; d/c 8/21/19 Added - Physical abuse; d/c 8/23/19 8/21/19 Added - [MEDICAL CONDITION], restlessness (This is the only behavior the facility is currently tracking on a daily basis) 2/12/20 Added Personal space intrusion 2 days after IJ determination - The facility was not tracking or trending the incidents of sexual statements to staff or residents or how many times he was intruding in others personal space, or attempting to inappropriatley touch other female residents or staff. On 2/12/20 at 7:55 AM, Surveyor asked DON B why R22's behavior monitoring was discontinued. DON B stated she started at the facility in September 2019 and was unsure why behavior monitoring was discontinued. Surveyor asked DON B if the facility tracks R22's behaviors related to intruding in others personal space, attempting to inappropriately touch other female residents, sexual statements, etc. DON B stated, No, but we could certainly add that. Surveyor asked DON B do you expect staff to follow care plans? DON B stated yes. The following is an excerpt from the 3/7/19 Surveyor interview with R113 immediately after R22 kissed R113 on the mouth. Note, identifiers have been change to match the identification key for the 2/12/20 survey. On 3/7/19 at 10:47 AM, Surveyor stepped into the Nurses Station and heard RN C start yelling. RN C started yelling and removed R113 from the TV room to the table right outside the TV room. RN C stated in a loud and frustrated voice, This is what I'm talking about! RN C stated R113 was in the TV room and RN C just observed him kissing R113. RN C stated she will call the physician and let DON B know. RN C stated DON B will let NHA A know. Surveyor asked, what about the family. RN C stated, yes, she will notify the family too. On 3/7/19 at 10:48 AM, Surveyor went into the TV room and spoke with R113. Surveyor asked R113 what just happened. R14 stated, He should shut up and stay away! Surveyor asked R113 how did it make you feel when R22 kissed you. R113 looked from side-to-side with a confused look on her face as she was thinking. R113 stated, Are you talking to me, bam! Are you saying R22 was talking to you and then all of a sudden he kissed you? R14 stated, Yes. R113 stated, I don't like that! Surveyor asked R113 if R22 has kissed you before. R113 stated, Yeah, I think so. Surveyor asked R113 do you know when he kissed you before. R113 stated, No. R113 stated, I didn't know what the hell was going on! Surveyor asked R113 does it bother you when R22 kisses you. R113 said, Yeah. Surveyor asked R113 do you feel safe. R113 stated, I didn't. Surveyor thanked R113 for sharing her feelings and exited the room. (It is important to note that the TV room has glass doors.) R22 was sitting at the table right outside the TV room, about 15-20 feet away from R14. Surveyor was standing outside of the TV room and observed R113 exit the TV room, approximately 1 minute after Surveyor left the TV room. R113 sat down at the table across from R22 and as she was sitting down she stated, Oh, that's scary! as she was looking at R22. Note, on 3/7/19 when Surveyor interviewed R113, despite her cognitive deficits, she clearly expressed her shock and anger as a result of R22's unwanted sexual contact. On 4/25/19 the facility moved R22 from the MCU to the general population on the 200 wing. On 11/6/19 the facility moved R22 back to the MCU after multiple incidents of aggression against other residents, including female residents. On 12/15/19 R22's NN (Nurses Note) states: Incident Type: Observed kissing female peer (R23) Date of Incident: 12/15/19 Time of Incident: 8:30 PM Location: Common area near lounge Resident's Condition Prior: Normal for resident, confused Activity at the Time: Standing in common area near lounge Equipment Involved: None Injury: None Injury location: na (not applicable) Injury Measurement: na First aid: None needed Vitals: None needed Neuro Checks: None needed Staff involved: CNA observed Witnesses: Staff Physician Notification: R22's Physician Family/Contact Notification: R22's family ok Intervention applied immediately to prevent recurrence: Separated from female peer Assessment Supporting Intervention: Separating from female peer will cease behavior On 12/15/19 at 10:53 PM, Staff noted the following in R22's medical record: Manifested by Decreased awareness for personal boundaries, increased affection towards peers of the opposite sex, physical affection (kissing, hand holding, etc.), Inappropriate contact with female peer. Staff will intervene/separate from female peer to maintain appropriate behavior. Note following the incident on 12/15/19, the facility did not modify R22's care plan with measures that more proactively protected female residents. On 12/31/19 at 8:08 AM, RN C (Registered Nurse) documented the following NN in R22's electronic medical record: Incident Type: Unknown kissing R113 Date of Incident: 12/31/19 Time of Incident: 8:00 AM Location: Dining Room Resident's Condition Prior: Normal for resident Activity at the time: Walking Equipment Involved: None Staff Involved: RN C, CNA F, and CNA G Witnesses: RN C, DON (Director of Nursing) Physician Notification: Physician Notified at 8:02 AM, Awaiting return call Family/Contact Notification: R22's Guardian, Awaiting return call Time of Notification 8:03 AM Intervention Applied Immediately to Prevent Recurrence: Supervised activity involvement Assessment Supporting Intervention: Resident wanders throughout unit Note, there is no evidence of how long the facility implemented Supervised activity involvement. This intervention was not added to the Care Plan or CNA Care Card. There is no evidence that this was communicated to staff via the 24 hour report. Instead (below), the facility followed up with the Psychiatrist to request a medication change, which is a reactive versus proactive response to address R22's sexualized behaviors. The facility did not modify R22's care plan with measures that more proactively protected female residents. On 12/31/19 at 9:19 AM, R22's NN states: Called placed to clinic and spoke with the Psychiatrist's Medical Assistant regarding: incident and being more intrusive to others personal space. Also physical interaction with peer last evening (Note this altercation was with R113's husband, who is also a resident on MCU and shares a room with R113.) Update that med (medication) change is being requested. She will update the Psychiatrist and call back with orders or plan. On 1/3/20 at 11:27 PM, R22's NN states: Observed increased agitation/aggression early PM. Res wandering and soliciting female staff for sex, making sexual comments and propositioning staff for f__king ([***] ing). Staff redirected conversation res (resident) replies with no one has to know, we can do it hard and fast. Episode lasted for 2 hours with constant redirection to L (left) hub and encourage area that was quieter on unit at that time. Res cooperative with HS (bedtime) meds. On 1/7/20 R22's primary Physician wrote an order to Increase Trazadone from 25 mg (milligrams) to 50mg at HS (bedtime). On 1/13/20 at 2:33 PM, RN C documented the followintg NN in R22's electronic medical record: Incident Type: Resident seen kissing R113 Date of Incident: 1/13/20 Time of Incident: 1:45 PM Location: Dining Room (*later corrected to television room, see below) Resident's Condition Prior: Normal for resident Activity at the time: Kissing Equipment Involved: None Injury: No apparent injury Staff Involved: RN C, CNA H (Certified Nursing Assistant), and CNA E (Certified Nursing Assistant) Witnesses: Staff Activity Personnel Act Asst I (Activity Assistant) Physician Notification: Physician Notified at 12:00 PM (note, this is before this incident occurred) Response: Assistant voiced that she will let the doctor know Family/Contact Notification: R22's Guardian Response: Is he getting worse? Intervention Applied Immediately to Prevent Recurrence: Residents were separated from each other; observation maintained, structured activity encouraged Assessment Supporting Intervention: Resident was focused on television show, engaged in conversation with staff *1/13/20 at 6:42 PM, Late Entry by RN C: 1/13/20 incident occurred in television room It is important to note that the sexual abuse that occurred on 1/13/20 involved the same residents, R22 and R113, in the same location as the occurrence on 3/7/19. On 1/13/20 the facility self-reported the following resident to resident incident: Briefly describe the incident: R22 was observed having his hands up R113's shirt and they were kissing. Residents were immediately separated and assessed. Residents placed on line of sight until team reviewed. Law enforcement was notified. MD's (Medical Doctors) and guardians updated. Describe the Effect that the incident had on the affected person, the person's reaction to the incident, and the reaction of others who witnessed the incident: Affected resident was immediately assessed for any signs or symptoms of emotional or physical harm. resident interviewed but d/t (due to) her cognitive status she is unable to have verbal communication. She showed no signs of physical harm via assessment or emotional harm via facial expression or verbalization. See attached documents. Explain what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct: Residents were immediately separated. There were no other resident witnesses. Employees were educate to protect affected person and others from further misconduct. Staff (Act Asst I) (Activity Assistant) witness statement is attached. Act Asst I's typed statement, signed by Act Asst I, states as follows: Monday, 1/13/20 approx (approximately) 1:30 PM. Returning from lunch. I entered the MCU to see R22 and R113 in tv/lounge area. R113 was in far left corner by window. R22 to her right with his left arm around her neck, left arm (correction, per interview, it is his right arm under her shirt) under her shirt. I separated the two. Taking R22 out of the lounge and then sending R113 to left area of MCU-headed toward dining area. Reported to nurse, had C.N.A. assist in this situation. On 1/13/20 at 2:30 PM, the facility contacted the police department regarding this incident. The police report states as follows: Staff called to report that R113 and R22 were kissing and R22 was touching R113's breasts. R113 said she knew what happened but was not violated. R22 was not happy I was not letting him have any fun. Just needed a case number for federal reporting. No crime as both parties suffer from dementia. Note, the Ombudsman will be meeting with the police department to provide education to them regarding dementia and how to determine a person's ability to consent. R113 was sexually assaulted and neither resident has the ability to consent to a sexual relationship. On 1/13/20 the facility provided training to staff and recorded this on the Group Employee Inservice Attendance Record. Subject Presented: R22 cannot be within arms reach of any female peers. Report any negative interactions to nurse immediately. 1/14/20 at 11:23 AM - Late Entry for 1/13/20 Spoke with: Message left for Psychiatrist to send new script for [MEDICATION NAME]. Call Placed to: Clinic Spoke with: Message left to have order for [MEDICATION NAME] increase to specific pharmacy On 1/28/20 R22's Psychiatrist documented the following note: Reason for Appointment: Recheck Assessments 1. Dementia with behavioral disturbance, unspecified dementia type Treatment: Start [MEDICATION NAME] (an antipsychotic) Tablet, 5 mg, 1 tablet in the morning, Orally, Once a day. Continue Aripiprazole (the generic name of [MEDICATION NAME]) tablet, 2mg, 1 tablet, Orally at night Notes: He was very aggressive with his last act of sex with another resident. (This is referring to the 1/13/20 incident with R113.) Will raise the [MEDICATION NAME] to 5mg in the morning and continue the 2mg in the evening. He did not look to be overly sedated at all. He was seen at 10:45 AM. History of Presenting Problem: Discussed patient with DON today. 1/15/20 dose raised to 2 mg BID for sexual aggression. He is a bit better but still has sexualized talk and behavior. He does not sleep great at night, just on and off. No diurnal change of functioning. Afternoons are not a lot worse than mornings. DON B wondered about hormonal therapy for sexualized behavior and I referred her to the patient's PCP (Primary Care Provider). He does seem less agitated with the dose increase in the [MEDICATION NAME] and less seeking out of sex. Examination - Psychiatry Appearance: Well-groomed well-nourished appears stated age. Was calm and pleasant. Abnormal body movements: None Affect: Appropriate full range Attention: Fair. He was seen in the special care unit (MCU) and was sitting in the TV lounge in a recliner. He acknowledged me sitting down near him in he chair. Attitude: Cooperative Insight: Poor Intelligence (estimate): Average but with dementia Judgement: Poor Mood: He says he likes living here and that the people are good to him Orientation: Moderate dementia Perceptual Disorders: No perceptual disorder noted Psychomotor Activity: Within normal range Speech: Clear normal Thought content: Paucity (the presence of something only in small or insufficient quantities or amounts; scarcity) of thought. He only tried to answer my questions but was not always able to. Surveyors entered the facility on Sunday, 2/9/20 at approximately 7:25 AM, for the facility's recertification survey, multiple complaints, and self-report (for the 1/13/20 sexual abuse incident). On 2/9/20 at 7:50 AM, Surveyor observed R22 seated at the table outside the tv area wearing gripper socks. R22 was watching staff and residents move around the dining room. R113 was seated 2 tables over from R22 (to R22's left). On 2/9/20 at 8:27 AM, Surveyor was standing behind R22 and observed R22 look to his right, then to his left (presumably scanning the unit for staff and acting willfully while no staff were present) and R22 stood up from his chair in the dining room and started ambulating independently. Surveyor observed there were no staff members in sight. R22 waited until all 3 staff members went into a shared resident room to get up a start ambulating in the dining room. LPN N (Licensed Practical Nurse), CNA E and CNA F were in R47 and R32's shared room. LPN N was passing medication and CNA E and CNA F were providing cares. This lack of supervision observed by Surveyor could have easily allowed another incident of sexual abuse to occur. Note, CNA F did not receive training following the 1/13/20 incident between R22 and R113 indicating R22 cannot be within arms reach of any female peers. On 2/9/20 at 8:29 AM, Surveyor observed CNA F exit R47's room after assisting him, and redirect R22 to sit back down at the table for breakfast. R22 then sat back down at the table. Surveyor observed there was no staff observing R22 for approximately 2 minutes while he was up ambulating independently in the dining room with R113 and other female residents just a short distance away. Per interview with Activ Asst D (Activity Assistant)he was schedule to start at 8:00 AM, but he was detained due to the road conditions and arrived at 8:30 AM. The facility did not provide a proactive solution (1:1 or line of sight monitoring) to prevent further abuse from occurring. If R22 is not on 1:1 or line of sight, the facility cannot ensure that the CP intervention of, R22 Needs to stay an arms length distance away from female peers is being implemented, therefore, not ensuring safety of female resdients on the MCU. On 2/9/20 at 9:02 AM, Surveyor observed a female resident, R14, approach R22 while he was seated at the dining room table for breakfast. R14 is seated in a low broda chair and put her bare foot up on R22's left shoulder. R22 did not react. R14 pulled her foot off of R22 and continued to propel around the dining room. No staff attempted to intervene when R14 had her foot on R22's shoulder. It is important to note that R14 was not kept an arms length distance away from a female peers per R22's comprehensive care plan and CNA care card. No staff intervened. On 2/9/20 at 3:05 PM, Surveyor spoke with CNA E. Surveyor asked CNA E if there has been any resident to resident incidents on MCU over the last couple months. CNA E stated, We keep R22 sitting separate from all women. CNA E stated she has not observed any incidents recently. Surveyor asked CNA E what prompted them to keep R22 away from women. CNA E stated that,R22 will sometimes go towards R113. CNA E added, They are thinking he targets R113 and told us to keep them apart. CNA E added, He seems to know right from wrong. Note, When R22 continually targets R113, it is not inadvertent or accidental, but a willful and deliberate act. Surveyor asked CNA E how does R113 react? CNA E stated that R113 is in her own world or she can be sleeping - she seems unphased. Sometimes she is antsy and bored and wanders around. Her Husband has been a resident on MCU for about 2 months and shares a room with R113. CNA E stated she did not observe R22 make contact with R113 but heard that there was was contact. CNA E stated, I heard he touched her, I'm unsure where, but police were called. Surveyor asked CNA E have you had an training recently? CNA E stated, she had training on 1/13/20 following the incident. CNA E stated we have a huddle every day and discuss residents. CNA E stated, with regards to R22, we make sure he's toileted and watching tv in his recliner, and we lay R113 down after lunch. CNA E stated R22 doesn't like to stay in bed. We try to keep R22 or another group sitting together. We keep the men together at tables. CNA E stated, We try to keep the ladies away from R22. CNA E added, R22 walks or stands around. CNA E stated, He has been pretty mellow the last few weeks (Note, this is likely due to the medication changes.) There was an incident with R23 that prompted R22 to be moved to the general population and arguing with a R32, a male resident (R22 was moved to general population on 4/24/19.) They (R22 and R32) don't argue anymore. We're supposed to have someone keeping an eye out here; a lot of time the Activity person will keep an eye out, during the week it's usually Act Dir X (Activity Director). CNA E added, almost all residents are 2 assist. CNA E stated, It's way better with 3 CNA's back here. I do feel like it's necessary. 2/9/20 at 3:25 PM, Surveyor spoke with CNA G. CNA G worked as an RA (Resident Assistant) from March to August before becoming a CNA at the facility. CNA G stated she works on MCU as well as other units. Surveyor asked CNA G if she observed or is aware of any resident to resident incidents on the MCU. CNA G stated there has been a couple times we needed to move R22; we redirect him away from females. We have to watch R14 due to previous incidents already investigated. CNA G stated in her most recent training (unsure when, but not recent) we talked about how to intervene, redirect, reporting, they had us sign a paper. CNA G stated, If they educated in January I probably had a day off. It is important to note that CNA G is not listed on the training for the 1/13/20 incident. The last I remember was an incident between R22 and R113. Surveyor asked do you know what happened? R113 is a a lovey person. If I'm doing charting she will come up and rub my shoulder, obviously that gets taken the wrong way (when it's another resident). Any idea how that situation happened? I have no idea.' Did R113 seem affected after the incident? CNA G replied, No. CNA G stated with R22, in the afternoon she has noticed he tends to look longer at R113, R14 and R23. Surveyor asked CNA G how many CNA's are usually on the floor? CNA G stated, the average number of CNA's on AMs for MCU is 2 CNAs and around 7:30 or 8:00 AM, Act Dir X is here. I let whoever know who's out here to come & grab me & to observe while 2 CNAs in a room. On 2/10/20 at approximately 9:00 AM, Surveyor spoke with CNA F. Surveyor asked CNA F if there have been any recent resident to resident incidents on the MCU. CNA F stated, 'We try to keep R23 and R22 apart. CNA F stated there was an incident with R22 but it's ok now because we lay him down after lunch. CNA F stated R23 and R22 tried to kiss each other, but he is unsure if they kissed. Surveyor asked are there any special interventions for R22? CNA F stated, We move him to his room or redirect, it's just R23 and him that need to be separated.Surveyor asked does R22 seek out any female residents? CNA F stated, R23. CNA F stated he doesn't recall him seeking out anybody else. CNA F stated we usually don't put a female by him due to previous the incident with R23. Note, CNA F is not aware of the CP intervention of Needs to stay an arms length distance away from female peers. The facility did not provide training to CNA F following the incident on 1/13/20. On 2/10/20 at 9:40 AM, Surveyor spoke with Act Dir X. Act Dir X stated she was informed We need to keep R22 one

Based on observation, interview, and record review, the facility did not implement professional standards of practice to prevent PIs (pressure injury) from developing or worsening for 1 of 1 resident reviewed for PIs, out of a sample of 20 residents (R213). R213 developed a Stage 2 PI, on 1/21/20, which progressed to a Stage III PI on 2/11/20. The facility did not implement approaches to prevent the PI from reoccurring or worsening. Staff interviews confirmed staff were not providing R213 with repositioning at night. In addition, R213's PI was not assessed by a RN (Registered Nurse) upon discovery and new interventions were not put into place. This is evidenced by: The facility's policy, Skin Care Management, revised 11/19, states, in part: Provide skin care to residents that includes assessment, prevention of skin breakdown and management of pressure injury and other skin integrity concerns. 2. The Skin and Body Assessment Form is to be completed and if there is a significant change in the resident's condition, acuity or alterations to skin. 3. The Braden Scale pressure injury risk assessment will be completed. This assessment will also be completed if there is a significant change in the resident's condition, acuity or alterations to their skin. The risk assessment scoring, comprehensive clinical evaluation will assist the interdisciplinary team for the development of the care plan. 6. When the resident is admitted with or develops a pressure injury or any other open area, immediate treatment will be initiated. R213 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R213's recent MDS (Minimum Data Set), dated 10/8/19, indicates a BIMS (Brief Interview of Mental Status) score of 99 which indicates severe cognitive impairment. R213's POA (Power of Attorney) is activated. R213 requires extensive assist with bed mobility and transfers. R213's Comprehensive Care Plan, dated 1/8/20 revised 1/27/20, indicates R213 has a Stage 2 PI to the gluteus. R213's Comprehensive Care Plan states, in part . Potential for skin integrity. Related to:[MEDICAL CONDITION] needing assistance with transfers. History of Incontinence. Nurses: Assess skin status. Keep MD (Medical Doctor) informed, follow medical plan for treatment, skin treatment per MD orders. Nurse Aide: Encourage and assist to reposition. Elevate resident's heels off of bed. Inspect skin daily. Report changes. CNA (Certified Nursing Assistant) Assignment Sheet indicates, Turning/Repositioning: Assist of 1 to turn and reposition as needed; turning and off load pressure every 2 hours. Off load pressure to heels with pillow when in bed. Skin Care: 1 assist with all cares, chart refusals. R213's Physician Orders, dated 2/4/20, indicate the following which were initially written on 1/21/20 Skin Treatment: Cleanse coccyx area with wound cleaner, pat dry. Apply Cavalon barrier to outer edges and allow to dry. Cover with [MEDICATION NAME] foam dressing and change every other day. Of note: this order is not listed on the TAR (Treatment Administration Record) or MAR (Medication Administration Record). R213's recent Braden Score of 17, dated 2/4/20, indicates R213 is at risk for PI development. On 2/4/20, Review of the Facility document titled, Skin Care Flow Sheet states, PI stage II to the coccyx. Area measured 0.5 cm (centimeter) x 0.3 cm, wound base moist and pink. Nurse's note on 2/4/20 includes, in part: Physician visit: No new orders. Physician viewed the stage II pressure area at this time. Without the signs of infection. On 2/9/20 at 9:31 AM, Surveyor observed R213's treatment by LPN V. LPN V stated she and DON B are currently enrolled in the wound care certification course and usually complete assessments together. Surveyor asked LPN V if she could describe the wound bed. LPN V indicated she would rather have DON B describe the wound as she is unable to assess or stage it. From 2/9/20 to 2/11/20 Surveyor observed on 6 separate occasions R213 lying supine in bed with his heels on the standard mattress. On 2/11/20 at 1:53 PM, Surveyor observed R213's dressing change by LPN V and DON B. R213 was lying supine in bed asleep with his heels in direct contact with standard mattress. Surveyor asked DON B if she could stage R213's PI to the coccyx. DON B stated, It looks like some slough, so moving toward a stage 3. Area on coccyx measured 0.5 cm x 0.5 cm x 0.1 cm with 95% (percent) slough in the wound bed. Surveyor asked DON B what interventions are in place for R213's PI. DON B stated, R213 is not on any protein supplements. R213 is on a repositioning schedule, has a chair cushion and is a check and change for incontinence. Surveyor asked DON B if another mattress was considered for R213 as he was on a Panacea pressure redistribution mattress. DON B stated, We could but the worry is that his falls may increase. On 2/11/20, Skin Care Flow Sheet states, PI stage III to the coccyx. 0.5 cm x 0.5 cm, wound base 95% slough and 5% red. Worsening of PI - MD updated. Dressing of [MEDICATION NAME] foam QOD. (Of note: The PI worsened and the treatment remained the same). Nurse's note from 2/11/20, includes, in part: Weekly Skin Assessment: Slough noted to 95% of wound, yellow slough. This is a change in the status of this wound. Measured 0.5 cm circular x <0.1 cm deep. R213 has an area of irritation noted to 6:00, 0.3 cm circular that does have tape irritation. R213 has a 6 cm surrounding periwound area that is blanchable at this time. Continue same dressing, but updating MD for further direction. R213 continues to refuse to reposition as he wants to lay on his back. Staff continue to check and change every 2 hours for incontinence. Nurse's note dated 2/12/20, states, New mattress was placed on 2/11/20 after assessment. R213 did not have heels on pillow to offload pressure, this was done on 2/12/20 by writer. CNA reminded to offload pressure from heels. R213's TAR, for February 2020, does not include any treatment orders for PI to the coccyx. On 2/6/20 Surveyor received the manufactures recommendations from Direct Supply which provides the following guidelines for all Panacea mattresses: WARNING - This mattress is not intended for stage III or IV pressure ulcers. Mattress wound stage ratings are general usage guidelines. A user-specific assessment performed by a medical professional could alter your particular usage of this mattress. On 2/11/20 at 3:00 PM, Surveyor observed Maintenance R bringing a mattress to R213's room. Maintenance R indicated R213 was getting new mattress. On 2/11/20 Surveyor received the new mattress recommendations for the SPAN, Pressure Guard CFT, and indication for treatment of [REDACTED]. On 2/12/20 at 6:58 AM, Surveyor interviewed LPN X regarding R213's plan of care. LPN X stated, R213 got a new mattress last night. Surveyor asked LPN X if R213 has a turning or repositioning schedule. LPN X stated, When he is asleep we just normally leave him alone. On 2/12/20 at 7:18 AM, Surveyor interviewed DON B regarding R213's positioning in bed. DON B stated, He should not be flat on his back and his heels should be floated. Sometimes he can get agitated and won't let us reposition him. Surveyor asked DON B if the risks and benefits of refusals have been reviewed with R213 or his guardian. DON B stated, No. R213 developed an avoidable PI. The facility did not follow care plan interventions or ensure appropriate treatments were in place when the PI worsened.

Based on observation, interview, and record review, the facility did not ensure that a resident having pressure ulcers received the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents (R1) reviewed for treatment and prevention of pressure ulcers. R1 was admitted to the facility without a pressure injury (PI) and was identified to be at risk for development. On 11/22/19, the facility identified that R1 had a reddened area on the back of right knee (popliteal). The facility did not notify R1's physician, obtain a treatment order, or monitor the reddened area. R1 developed a facility acquired PI, which worsened from a reddened area to an Unstageable PI. Evidenced by: The facility policy entitled Skin Care Management, revised 11/2019, states, in part: It is the policy of this nursing home to provide skin care to residents that includes assessment, prevention of skin breakdown and management of pressure injury and other skin integrity concerns. 5. Skin is monitored routinely during care giving, and problems identified will be documented on the Skin and Body Assessment Form. Skin integrity will be monitored at least weekly on the resident's bath day for all residents that are identified at risk. For residents with medical devices, skin will be inspected on every shift under and around devices for signs a symptoms of pressure-related injury to surrounding tissue. 6. c. Measurement of the area will be done using a wound measuring guide. 6. d. A weekly assessment and associated documentation will be done by the nurse using the Skin Care Flow Sheet (or electronic equivalent). If paper-based, this will be filed in the Assessment section of the resident's record upon completion. Staging of Pressure Ulcers: The facility follows the National Pressure Injury Advisory Panel (NPIAP- formerly NPUAP (National Pressure Ulcer Advisory Panel)) guidelines for Prevention and treatment of [REDACTED]. Pressure Injuries are staged using the system below: Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured serum filled blister. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present, but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. *Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined . The facility policy entitled Change in Residents Condition/Status, Resident, Physician and Family/Legal Representative Notification/Consultation, revised 4/2018 states, in part: Purpose: This facility will promptly notify (and consult with, when appropriate) the resident, the resident's attending physician and the resident's legal representative or interested family member of changes in the resident's condition and/or status. Protocol: 8. The Licensed Nurse will record in the resident's medical record the notification of resident, physician, and resident's representative of the change in a resident's condition or status. R1 was admitted to the facility, on 8/17/18, with [DIAGNOSES REDACTED]. R1's most recent Minimum Data Set (MDS), dated [DATE], documents a score of 15 on Brief Interview of Mental Status (BIMS), which indicates R1 is cognitively intact. Section G indicates R1 is extensive assist for bed mobility and transfer. Section M - M0150 indicates R1 is at risk for PI development. M0210 indicates R1 has one or more unhealed PIs. M0300 indicates R1 has a Stage II PI. The facility's Skin Care Flowsheet indicates the following information: Date of Origin: 11/22/19 Present on Admission: No Facility Acquired: Yes Written description of wound: Friction wound from w/c (wheelchair) 5.0 x 2.0 cm (centimeters) Wound Type: Friction rub Wound Base: Red diffuse Exudate Type & Amount: NA (Not applicable) Odor: NA Presence of Pain: NA Healing Progress: Irritated intact Treatment: Sheepskin to wheelchair edge R1's care plan, dated 11/25/19, entitled 'Tissue Integrity Impairment related to decreased mobility, insists on sitting in wheelchair most of time, noncompliance with care plan, heat, moisture and diabetes mellitus (DM),' states, in part: encourage to reposition out of wheelchair to other seating arrangement for better compliance/elevation, inspect skin every shift, report changes. On 11/25/19 at 11:20 AM, Surveyor observed CNA D (Certified Nursing Assistant) toilet and provide pericare to R1. While R1 was standing, Surveyor observed a lesion that was black in color on the back of R1's right popliteal (the hollow at the back of the knee.) On 11/25/19 at 11:25 AM, Surveyor spoke with R1. Surveyor asked R1 how long she has had the area on the back of her knee. R1 stated not long. R1 stated she thinks she got this from it rubbing on her wheelchair cushion and the facility put sheepskin on her cushion. R1 stated that she does not want a different wheelchair cushion. Surveyor asked R1 if the facility puts dressings on the back of her knee. R1 stated, No. Surveyor asked R1 if she receives treatments to her legs and feet when she is supposed to. R1 stated, No. On 11/25/19 at 3:12 PM, Surveyor observed DON B (Director of Nursing) perform the dressing changes to R1's bilateral legs and feet while NM C (Nurse Manager) assisted. After the treatments to R1's legs were complete, Surveyor requested to observe R1's popliteal. When NM C saw R1's popliteal fossa she stated it looks much worse than it did on Friday, when she first noted it. NM C stated when she first noted the area it was reddened. Surveyor asked NM C how you would describe the wound on the popliteal fossa. NM C stated, Necrotic, at least a Stage II. DON B stated that it was just a Scab. NM C stated, on 11/22/19, that R1 requested an ABD pad to put between the popliteal and the [MEDICATION NAME] and the facility provided this to her. On 11/25/19 at 4:15 PM, Surveyor spoke with DON B and NM C. Surveyor asked DON B and NM C if they are Wound Care Certified. DON B and NM C stated they are not Wound Care Certified; however, NM C stated she previously had worked in a Wound Care Clinic. Surveyor stated to NM C that she had previously stated the wound was Necrotic, at least a Stage II. Surveyor asked NM C, if a wound is Necrotic, what stage is it. NM C stated the wound is Unstageable. Surveyor asked NM C, if a resident has a skin impairment, how soon should the physician be notified. NM C stated, As soon as we know it's there. NM C stated, Did I do that, no. NM C stated she should have contacted the physician to notify of the skin impairment and to obtain an order for [REDACTED]. The facility has no documentation that the physician was notified of this new skin impairment or that it was being monitored over the weekend. The skin impairment worsened to an unstageable ulceration. The facility failed to notify the physician when they first identified the skin impairment, put a treatment in place to promote healing, and closely monitor the area. (Of note, according to the NPIAP, if a wound is covered with slough and/or eschar, the area would be considered Unstageable, as the depth cannot be determined. Staging a PI a Stage 2 with visible eschar would be incorrect staging. On 11/26/19 at 2:00 PM, Surveyor followed up with NHA A (Nursing Home Administrator). NHA A stated the facility's Medical Director looked at R1's popliteal fossa this morning and stated it was a Scab and to cover it with a Band-Aid. R1 has her next appointment with the Wound Care Clinic on 11/27/19. Surveyor asked NHA A if there is a Wound Care Certified Nurse in the building. NHA A stated, no, there is not, but they would like to get either DON B or NM C Wound Care Certified and NHA A agrees this would be beneficial. The facility provided additional information, 11/27/19, as follows: Physician Order, dated and signed 11/26/19, states, in part: Vaseline to Eschar area daily with gauze dressing. Padding around wound. Physical Therapy (PT)/Occupational Therapy (OT) evaluation and treatment for [REDACTED]. Wound Clinic Notes, dated 11/26/19, states, in part: Reason for Appointment: Wound Check. Assessment: Pressure injury of right knee, stage 2. Treatment: 1. Pressure injury of right knee, stage 2. Notes: Stage II pressure injury right knee: The first and most important issue is to provide offloading of this wound site and will have PT and OT evaluate her wheelchair seat cushion and provide some form of padding surrounding the ulcerated area. To help soften the eschar as it appeared quite adherent, I recommended moisturization with the use of Petroleum Jelly, to cover the area use a gauze dressing over the surface, and try and prevent friction or irritation to this area on a daily basis. General examination: patient was noted to have a stage II ulcerated area just directly about the popliteal fossa region of the right knee. It had a central dry eschar but did not appear necrotic in nature. She has a circumferential surrounding area of [DIAGNOSES REDACTED], in the largest diameter it measures approximately 2.5 centimeters (cm). This appears to be consistent with a direct pressure-type ulcer from her wheelchair. (Of note, according to the NPIAP, if a wound is covered with slough and/or eschar the area would be considered Unstageable, as the depth cannot be determined. Staging a PI a Stage 2 with visible eschar would be incorrect staging. PT Notes, dated 11/27/19, state, in part: new dressing to right posterior thigh wound was 100% covered in non-viable tissue. Skin prep to periwound and Allevyn 3x3, Gentle border dressing to cover. R1 was at risk for developing a PI. R1 developed a facility acquired PI. The facility failed to update the MD (Medical Doctor), provide treatment and monitor the PI, which quickly worsened to an Unstageable PI.

Based on observation, interview and record review, the facility did not ensure residents receive care, consistent with professional standards of practice, to promote healing, prevent infection and prevent development of pressure injuries (PI) for 2 of 4 residents reviewed for wounds, out of a total sample of 12 residents (R10 & R3). R10 developed PIs that have deteriorated. Staff was not following R10's Physician order [REDACTED]. R10's Right (R) ischial PIs were not documented as being completed on the TAR or in the Nurses Notes on two separate occasions. RN (Registered Nurse) did not complete hand hygiene or use a clean pair of scissors when completing R10's dressing change. R3 had a facility acquired PI and physician ordered treatments were not being performed. This is evidenced by: Facility Policy entitled Skin Care Management, with review date of 6/2017, states, in part: It is the policy of this nursing home to provide skin care to residents that includes assessment, prevention of skin breakdown and management of PI and other skin integrity concerns. Protocol: .2. The Skin and Body Assessment Form is to be completed as instructed above at the time of admission, quarterly, and if there is a significant change in the residents condition, acuity or alterations to skin .a. If any pressure or other skin ulcers are found during an assessment the Skin Care Flow Sheet (or electronic equivalent) is to be completed and maintained until the area is healed and for 30 days after. If paper-based, all assessments are to be filed in the assessment section of the medical record when completed.8. The Skin Care Flow Sheets will be reviewed through PAR (Performance Annual Review) and through the QAPI (Quality Assurance and Performance Improvement) Committee and any change in care, treatment, nutritional support, etc. will be determined and documented. The care plan will be reviewed and updated as appropriate by the Interdisciplinary Team (IDT). Skin Treatment Management Guidelines .Stage 1 PI non-blanchable [DIAGNOSES REDACTED] of intact skin.Stage 2 PI: Partial thickness skin loss with exposed dermis. 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.Stage 3 PI: Full-thickness skin loss, in which adipose is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar (dead tissue) may be visible. The depth of tissue damage varies by anatomical location; .if slough or eschar obscures the extend of tissue loss this is an Unstageable PI.Treatment Guidelines: .Re-evaluate bed and wheelchair surfaces. Re-evaluate/implement prevention interventions. Update care plan/CNA (Certified Nursing Assistant) Assignment Sheet.Stage 4 PI: 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 . Unstageable PI: 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 PI will be revealed. Treatment guidelines: .Weekly re-assessment and documentation through end of healing plus 4 weeks.DTPI (Deep Tissues Pressure Injury): persistent non-blanchable deep red, maroon or purple discoloration . Facility Policy entitled Standard and Transmission-Based Precautions, revised 9/18, states, in part: Purpose: Standard precautions will be used in the care of all residents regardless of their [DIAGNOSES REDACTED]. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Other appropriate transmission-based precautions may be used as assessed on an individual resident basis. Protocol: 1. Hand Hygiene: a. Hand hygiene refers to hand washing with soap and water OR using alcohol-based hand rubs (gels, foams, rinses) that do not require access to water. B. Hands shall be washed with soap and water whenever visibly soiled with dirt, blood, or body fluids, or after direct or indirect contact with such, and before eating and after using the restroom. c. in the absence of visible soiling of hands, alcohol based hand rubs are preferred for hand hygiene .2. Gloves: a. wear gloves (clean, nonsterile) when you anticipate direct contact with blood, body fluids, mucous membranes, non-intact skin, and other potentially affected material. b. wear gloves when handling or touching resident care equipment that is visibly soiled or potentially contaminated with blood, body fluids, or infectious organisms . d. Change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body site to another . f. remove gloves promptly after use, before touching non-contaminated items and environment surfaces - and before touching another resident or leaving the room - and wash hands immediately to avoid transfer of microorganisms to other residents or environments. Example 1 R10 was admitted to the facility, on 4/27/16, with [DIAGNOSES REDACTED]. R10's Quarterly MDS (Minimum Data Set), dated 3/31/19, indicates the following: R10 has a BIMS (Brief Interview of Mental Status) of 13 out of 15, indicating R10 is cognitively intact. R10's MDS also indicates that she is dependent on staff for bed mobility, transfers, eating, and toileting. R10 has impairment to bilateral upper and lower extremities. Section M indicates that R10 is at risk for PIs and currently has one PI that is a Stage III. (Please note that R10 only has one PI at this time to her R Ischial on buttocks.) R10's Stage III R ischium wound #1 (origin date not specified on form), measurements are as follows: 3/28 - 0.5 cm (centimeter) x (by) 1.5 cm x 2.5 cm, wound base granulation tissue, moderate serous drainage, indicated as deteriorated - continue current plan of care (CCP[NAME]) 4/4 - 0.75 cm x 1.25 cm x 2.25 cm, wound base granulation tissue, moderate serous drainage, indicated as improved - CCP[NAME] 4/11 - 0.75 cm x 0.75 cm x 2.25 cm, wound base granulation, scant serosanguinous drainage, indicated as improved - CCP[NAME] 4/18 - 1.25 cm x 1.25 cm x 2 cm, wound base granulation, moderate serous drainage, indicated as deteriorated - CCP[NAME], physician updated 4/25 - 1 cm x 1 cm x 2.25 cm, wound base granulation, moderate serous drainage, indicated as deteriorated - CCP[NAME] 5/3 - 0.5 cm x 1 cm x 2 cm, wound base granulation, moderate serous drainage, indicated as no change - CCP[NAME] R10's Stage III R ischium wound #2, origin date 4/18/19, measurements are as follows: 4/18 - PI Stage III 0.25 cm x 0.25 cm x 1 cm, wound base is granulation tissue, with moderate serous drainage 4/25 - PI (no Stage specified) 0.5 cm x 0.5 cm x 2 cm, wound base granulation, moderate serous drainage, indicated as deteriorated. - CCP[NAME] 5/2 - Stage III 0.75 cm x 1 cm x 2 cm, wound base granulation, moderate serious drainage, indicated as no change. - CCP[NAME] R10's Unstageable L Ischium wound, origin date 4/25/19, measurements are as follows: 4/25 - PI 2.5 cm x 1.5 cm x 0.5 cm, wound base is necrotic 75% (percent) eschar (dead tissue) and 25% slough (dead skin that has fallen off) with moderate serous drainage - indicated as acute 5/2 - Unstageable 2 cm x 1 cm x 0.5 cm wound base is 75% slough and 25% granulation with moderate serous drainage. Indicated as improved - indicated as improved (Please note that based on observation and interview with RN C, on 5/8/19 from 2:08 PM to 2:36 PM, R10's wounds have deteriorated; all three wounds have slough present and R10's L ischial now has eschar present again, please references observation/interview with RN C.) R10's (MONTH) 2019 TAR is not signed out as providing wound care to R10's R ischial wounds, there is no indication in R10's Nurses Notes that either ischium wound dressing/treatment had been completed on 4/30/19. R10's (MONTH) 2019 TAR does not have R10's current L ischium wound treatment ordered, on 4/29/19, on the TAR. Therefore, there is no documentation to show that R10 received L ischial wound care treatment between 4/29 & 4/30/19. R10's (MONTH) 2019 TAR does not have initials on 4/1/19 for AM or N[NAME] (night) shift indicating whether R10 had her foam off-loading device under her. All other days for Skin treatment: check to ensure foam off-loading device appropriately positioned under and around R ischial PI every shift N[NAME] AM PM are signed out as being completed. (Please reference CNA interviews as they indicated R10 does not use this cushion.) R10's (MONTH) 2019 TAR is not signed out as providing wound care to R10's R ischial wounds and there is no indication in R10's Nurses Notes that either ischium wound treatment/dressing had been completed on 5/1 or 5/5/19. R10's (MONTH) 2019 TAR does not have R10's current L ischium wound treatment ordered, on 4/29/19, on the TAR. Therefore, there is no documentation to show that R10 received her L ischial wound care treatment between 5/1 & 5/7/19. There is no indication in R10's Nurses Notes R10 received these treatments on any day other than when R10's wound was measured on 5/2. R10's 2019 (MONTH) TAR all days for Skin treatment: check to ensure foam off-loading device appropriately positioned under and around R ischial PI every shift N[NAME] AM PM are signed out as being completed, except for 5/7/19 PM shift, which is indicated as refused. (Please reference CNA interviews as they indicated R10 does not use, refuses or does not like this cushion.) R10's CNA Assignment Sheet, printed on 5/7/19 at 1:10 AM, states, in part: Transfer assist: Assist of 2 full body lift .Turning/repositioning: Ensure foam off-loading U shaped support placed centered under R ischial PI at all times. Use lift sheet for repositioning, reposition and offload with turning side-to-side. No pressure on her ischial wound. Report refusals to reposition to Charge Nurse or Wound Nurse. R10's Nurses Note, dated 4/25/19 at 4:24 PM, by RN C, states: Disease make cognitive, ADL (adult daily living activities), or behavior unstable, fluctuating, precarious, or deteriorating: During wound rounds, resident observed with an Unstageable ulcer to the left ischium. Treatment applied per MD (Medical Doctor) order. Education provided to resident on importance Q (every) 2 hours in an attempt to prevent further pressure reviewed with resident. Resident in agreeance at time and allowed this writer and aide to repositioning (SIC) to the right side. Education and encouragement offered to resident related to getting out of bed Resident declines. R10's care plan, printed on 5/8/19, indicates the following: 4/10/19 Problem is impairment of skin integrity with the goal of R10's wounds to heal during review date with goal time of 7/10/19. Nurse Aides are to assist with hygiene and general skin care. Reposition frequently PROM (Passive Range of Motion) with AM and HS (bedtime) cares. Keep skin clean and dry. Use lift sheet when moving resident in bed, Air mattress on bed. Nurses are to assess skin condition daily and note any changes, change dressing, pressure relieving device(s) for bed. Provide ulcer care, (R10) must be turned side-to-side frequently. If (R10) refuses turning and repositioning, Charge Nurse is to chart refusals. 2/6/2019 Turning/repositioning: ensure foam off-loading U shaped support placed centered under R ischial PI at all times. 4/25/19 Turning/Repositioning: use lift sheet for repositioning, reposition and offload with turning side to side. No pressure on her ischial wound, report refusals to reposition to Charge Nurse or Wound Nurse, encourage not to keep HOB (head of bed) elevated for long periods to decrease pressure to buttocks, assist of 2. R10's Nurses Note, dated 5/7/19 at 1:05 AM, states, in part: .Right ischial wound cleaned and dressed, drainage brownish/red,; nil (SIC) offensive odor noted, nil (SIC) pain reported during procedure. To be seen by surgeon on 5/8/19 at 1100 (11 AM) on site. (Please note there is no indication if R10's L ischial wound dressing was completed at this time.) R10's Physician Orders, signed on 5/7/19, state, in part: 9/4/2018 PT (Physical Therapy) Order: obtain foam padding with hole over ulcer area to assist in off-loading weight to ulcer area, . 8/7/2018 Skin treatment: Check to ensure foam off-loading device appropriately positioned under and around right ischial PI every shift N[NAME] AM PM first date: 8/7/2018 (until resolved) 4/29/2019 Skin treatment: R ischium #1: Stage III - clean with normal saline or wound cleanser, pat dry. Pack with [MEDICATION NAME]. Cover with ABD (abdominal dressing) and secure with tape, daily AM. First date 4/29/19 (until resolved) Ordered by: (Physician name). Skin Treatment: Right ischium #2: Stage III - cleaned with normal saline or wound cleanser. Pat dry, pack with [MEDICATION NAME]. Cover with ABD and secure with tape, daily AM first date: 4/29/2019 (until resolved) Ordered by: (Physician name). Skin treatment: Left Ischium: Unstageable - clean with normal saline or wound cleanser. Pat dry, apply [MEDICATION NAME] to wound care (SIC) and cover with [MEDICATION NAME], every three days. First date 4/29/19 (until resolved) ordered by: (Physician name). On 5/7/19 at 2:00 PM, Surveyor spoke with R10. R10 indicated she did not have her PIs prior to coming to the facility. R10 was told it's her fault she has the PI's due to lying in bed all the time. R10 indicated staff is to be repositioning her, and she is lying on her back at this time. Surveyor did note a pillow under R10's left side at this time, but R10 does not appear to be offloaded on that side. R10 indicates her dressings were already done for the day and she was offered Tylenol prior to. R10 indicated dressings are changed every day, denied not having dressing changed recently. Blue circular cushion observed on nightstand by window. R10's Nurses Note, dated 5/7/19 at 3:18 PM, states, in part: She reported pain that was horrible/very severe. This information was given to the Charge Nurse. She localized the pain to her buttocks where she has 2 Stage III PIs and 1 Unstageable PI . her speech is clear, concise, appropriate. Current BIMS 13/15. (R10) is dependent for all ADLs r/t (related to) her [DIAGNOSES REDACTED]. On 5/7/19 at 4:05 PM, Surveyor observed R10 lying in bed at this time with a pillow under her left side, appearing to be in the same position, observed at 2:00 PM. On 5/7/19 at 4:07 PM, Surveyor interviewed CNA G regarding R10. CNA G indicated she did not receive any type of report regarding R10 refusing her cushion. CNA G indicated to Surveyor that R10 won't let you put the donut/cushion in, otherwise she will cry. CNA G indicated she has reported it to RN [NAME] and they put pillows behind her instead. CNA G knows the cushion is a Physician Order, but R10 cries, because it hurts her. CNA G indicated R10 has been refusing the cushion since she got it. CNA G stated, Probably laying in bed, I guess, when asked if she knew how R10 got her PIs. On 5/7/19 at 4:10 PM, Surveyor and RN [NAME] went to R10's room at this time. Surveyor asked RN [NAME] if R10 had her cushion under her. RN [NAME] rolled R10 to see if R10's cushion was under her. R10 denied refusing her cushion at this time and R10 denied asking to have it removed from under her. Surveyor observed R10's blue cushion to be on R10's night stand near the window. Surveyor interviewed RN [NAME] at this time regarding R10's cushion. RN [NAME] stated, It's horribly hard and hurts, indicating the cushion is hard and it hurts R10. RN [NAME] indicated to Surveyor at this time there is nothing under R10's bottom, and RN [NAME] was not told in report that R10 refused her cushion or by the CNA on the Wing. R10's Nurses Note, dated 5/7/19 at 5:08 PM, states, in part: impaired coping: at approximately 1600 to 1615 (4 PM to 4:15 PM), in the presence of state representative, resident consented for foam cushion to be administered as prescribed; however, when cushion was put in place resident voiced, That is the one I really hate, why are we doing this, then stated she did not want it there as prescribed. On 5/8/19 at 8:37 AM, Surveyor observed R10 lying in bed with pillows under her right side, boots on bilateral feet and alternating air mattress appears to be working. R10's cushion is observed not under her and sitting on the night stand by the window, appears to be in the same place as observed on 5/7/19 at 2:00 PM and 4:07 PM. On 5/8/19 at 8:52 AM, Surveyor interviewed CNA F regarding R10's cushion. CNA F indicated she did not see anything on the CNA Care Card regarding a cushion. CNA F did not know if R10's cushion was under her, then stated, I don't believe so. CNA F indicated that R10 refuses it. CNA F stated, No, I haven't, when Surveyor asked if CNA F offered/tried to place R10's cushion under her. CNA F also indicated that she believes R10's cushion has been out since night shift. On 5/8/19 at 9:00AM, Surveyor interviewed LPN D (Licensed Practical Nurse) regarding R10. LPN D indicated to Surveyor that R10 had her cushion under her when she received her medications earlier in the shift. LPN D indicated staff only takes the cushion out to reposition her, then put it back. LPN D indicated that they usually use pillows and not the hard blue cushion, due to R10 will voice it's hurting her. LPN D stated, Yep, when asked if base on Physician Orders, should R10 have her cushion under her. LPN D stated, No, indicating that using pillows instead of the cushion, is not following Physician Orders. LPN D indicated she is unaware that the cushion is not under R10 and is not aware if R10 refused to have her cushion under her today. On 5/8/19 at 9:45 AM, Surveyor interviewed DON B (Director of Nursing) regarding R10. DON B indicated she is unaware that R10 is refusing/does not want to have the cushion under her. DON B also indicated she was not aware that R10's treatments are not documented as being done. On 5/8/19 at 10:48 AM, Surveyor interviewed DON B and RN C regarding R10's wound documentation. RN C stated, No, indicating that R10's L ischium treatment is not on the TAR for (MONTH) or May. DON B indicated that the treatment order is in the Physician Orders, but not on the TAR. DON B and RN C both indicated that R10's treatment is to be on the TAR. Surveyor asked DON B and RN C if there is any further documentation to show that R10 received wound treatments for the L ischial wound, DON B and RN C indicated that RN C did R10's treatments with wound rounds. RN C and DON B indicated that R10's treatments were not documented and should have been. RN C indicated she has seen the cushion under R10 on wound measuring days. DON B indicated that she would expect CNA's to write the refusal down on their CNA Sheet and report it to the nurse. DON B would expect the nurse to put a note in and document the refusal on the TAR. RN C will be talking to the physician today about discontinuing the cushion device. (Please note that no further documentation was provided to Surveyor to indicate that R10's treatments were completed per Physician Orders.) On 5/8/19 at 1:30 PM, Surveyor observed R10 lying in bed with pillows on both sides of her. R10's cushion observed sitting on a stationary chair in R10's room near R10's bed, which indicates the cushion is not under her at this time. On 5/8/19 at 2:00 PM, Surveyor interviewed CNA F and CNA H. CNA F indicated to Surveyor that R10 agreed to have cushion under her for 2 hours, then wanted it removed, so CNA F placed pillows behind her shoulders, mid back and under her right leg. CNA H indicated that R10 complies when physician is here, than goes back to refusing. CNA H feels the physician needs to order something else instead of the cushion. CNA H indicated if R10 refuses, they place pillows under her and let the nurse know. On 5/8/19 at 2:08 PM, Surveyor observed RN C perform wound care on R10. Surveyor observed RN C set up her supplies on R10's over bed table. RN C performed hand hygiene then put gloves on. RN C used her clean gloved hands to pick up and use R10's bed control to bring R10's bed up to an appropriate height and put R10's head of the bed down. RN C used the same gloves, she touched the bed control with, to remove R10's old dressing, dated 5/7/19, from her R ischial wounds. After RN C removed the old dressing and wound packing, RN C turned and grabbed clean 4 x 4 gauze pads and the bottle of wound cleanser. RN C proceeded to clean R10's R ischial wounds while wearing the same pair of gloves. Once RN C was finished cleansing R10's R ischial wounds (both PIs/wounds are Stage III PIs), she then removed her gloves and performed hand hygiene. RN C indicated that R10's R ischial wound #1 has 50% white slough in it and that R10's R ischial wound #2 has deteriorated as it has slough in it now and RN C also stated, No slough in either last week; indicating that the slough is new in both R ischial wounds. RN C indicated the R ischial wound #2 is 75% slough and 25% granulation tissue. At approximately 2:20 PM, RN C changed her gloves and opened dressing change items and placed a pair of scissors on top of a blue chuck (disposable pad) that had already been under R10 prior to wound care. RN C packed R10's R ischial wound #1 with packing, then picked up the scissors and used them to cut the packing strip, then replaced the scissors down on the chucks. RN C then proceeded to move to R10's R ischial wound #2 and packed that wound with a packing strip and again picked up the scissors and cut the packing strip to size, then placed the scissors down on the blue chuck on R10's bed. Placed ABD over area, tapped in place then removed gloves to perform hand hygiene. (Please note that RN C did not measure R10's wounds at this time even though she verbalized deterioration of the wounds.) On 5/8/19 at 2:30 PM, Surveyor observed RN C perform wound care on R10's L ischial wound. Surveyor observed RN C remove R10's old dressing dated 5/7/19. RN C used the same gloves she used to remove R10's old dressing from her L ischial wound to grab clean 4 x 4 gauze pads and the wound cleanser. RN C then proceeded to clean R10's L ischial wound while wearing the same gloves. RN C then grabbed another clean 4 x 4 gauze pad to dry the L ischial area, while still wearing the same gloves. RN C described R10's L ischial wound as being Unstageable due to 75% eschar and 25% slough. RN C proceeded to remove her gloves at this time and perform hand hygiene, then continued R10's wound treatment with new gloves. RN C stated, It's better, indicating R10's L ischial wound has improved from last week to this week. (Please note, on 5/2, R10's L ischial wound was 75% slough and 25% granulation with moderate serous drainage and indicated as improved; however, eschar and slough are not the same. Slough is dead skin tissue that may have a yellow or white appearance where eschar is typically tan, brown, or black, and may be crusty. Please note that RN C went from dirty to clean by not changing her gloves between removing the old dressing and cleansing R10's wounds for both the L and R ischial wounds. RN C also placed her scissors on an unclean surface, then proceeded to use them to cut R10's clean packing strips. Additionally, R10's old dressings are dated 5/7 for all 3 wounds, yet there is no documentation, on 5/7, for the L ischium wound as being completed.) On 5/8/19 at 2:36 PM, Surveyor interviewed RN C regarding R10's wound treatment observation. RN C indicated hand hygiene is to be done upon entering the room, when changing gloves and when going between clean and dirty. RN C indicated the wound area is still dirty after removal of old dressing and she was going from dirty to dirty. (Please note the gauze RN C grabbed was clean.) RN C stated, No, indicating the chucks under R10 were not considered clean, and her scissors were no longer clean after being placed on the chuck. On 5/8/19 at 3:20 PM, Surveyor interviewed MD I regarding R10. MD I indicated this is his first time seeing R10. MD I indicated that R10 has MS ([MEDICAL CONDITION]) and sacral wounds, and unless R10 is turned every 20 minutes, pressure wounds will develop. MD I indicated that PIs are typically from not moving, unless enough staff to move someone every 20 minutes. MD I indicated what we are seeing is the tip of the iceberg and indicated there is probably a lot of tissue that is necrotic under R10's skin and only option is to open the area up. Surveyor asked MD I why R10 has her PIs. MD I indicated one can't prevent all wounds when immobile, unless enough staff to turn her every 20 minutes. MD I would expect the physician to be notified if dressings were not completed per order and with any type of deterioration or increase in size. MD I indicated R10's wound will not get better without surgical intervention. Example 2 R3 was admitted to the facility, on 10/7/15, and has [DIAGNOSES REDACTED]. R3 discharged from the facility on 3/10/19. On 2/27/19, a new PI located on R3's left lower extremity was identified. Facility documentation indicates the PI was a Stage II and measured at .5 x .75 cm, on 2/27/19, and 1 x 1 cm on 3/6/19. A Physicians Order, dated 2/27/19, called for treatment for [REDACTED]. R3's TAR has no nursing initials for the dates of 3/5/19, 3/7/19 and 3/9/19. No other documentation was found or supplied indicating R3's PI had healed, improved or been treated on the missing dates. On 5/8/19 at 2:12 PM, Surveyor interviewed RN C. RN C indicated she was doing most of the treatments, but was not sure if she had done the three missing treatments in accordance with R3's TAR. RN C stated she did not know why the TAR was not filled out, but should have been if the treatment was completed.

Based on observation, interview, and record review, the facility failed to prevent sexual abuse to residents R15, R19, R20, R14, and R22 and to other undocumented residents and which has the potential to affect all 16 females and 6 males on the MCU (Memory Care Unit). Two male residents that reside on the MCU are inappropriately touching other residents on the MCU. R1 is touching women on their legs, inner thighs, breasts and touching women and men on their genitals, by placing his hand down their pants or over their clothing. R13 is kissing other female residents. R13 kissed R14 on the mouth during this complaint investigation. R14 was upset that R13 kissed her. R14 stated to Surveyor, He should shut up and stay away! R14 stated, I don't like that! R14 further stated, I didn't know what was going on. Surveyor asked R14 if she feels safe. R14 stated, I didn't. The facility failed to do the following: 1. The facility was not providing 1:1 (one-to-one) per the care plan. 2. Staff did not separate residents to prevent further abuse from occurring. 3. NHA A did not acknowledge incidents of inappropriate contact as abuse, failed to investigate the incidents, and failed to prevent further abuse from occurring. The facility failed to keep their most vulnerable residents safe. Using the concept of a reasonable person, women and men don't want to be touched by strangers and would feel threatened, unsafe, and vulnerable if unable to defend themselves from unwanted sexual advances. The facility's failure to keep residents free from sexual abuse created a finding of Immediate Jeopardy (IJ) beginning 1/21/19. On 3/11/19 at 11:10 AM, NHA A was informed of the IJ. The IJ was removed on 3/7/19 after surveyors informed the facility that this would be looked at as potential immediate jeopardy. The deficient practice continues at a scope/severity level of [NAME] (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. Evidenced by: Example 1 R1 is a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. R1's BIMS (Brief Interview for Mental Status) is a 10 (Moderate Confusion) and has a Guardian. R1's Physician Note: 11/27/18 - Physician documented: Stop [MEDICATION NAME] tablet, 0.25mg (milligram), 1 tablet for mood and overly sexualized behavior at HS (hours of sleep (bedtime)), Orally, Once a day; Notes: Dose decrease; Notes: Patient has had no new major behavioral problems or issues. He is somewhat lethargic. I am going to discontinue low-dose [MEDICATION NAME]. R1's Physician Note: 1/2/19 - Physician stated: (R1) is on a minimum dose of [MEDICATION NAME] at this time and I am going to attempt to discontinue this. Staff will continue to monitor behaviors. If for any reason they are dangerous to self or others, could always consider reinitiating this. Hypersexuality: Notes: Adequately controlled with current dose of [MEDICATION NAME]. Will continue the same, and if (R1) again does not exhibit any major acting out with sexual behaviors, could do a gradual taper on his [MEDICATION NAME]. History of Present Illness - General: .No unusual sexual behaviors or problems. R1's CNA (Certified Nursing Assistant) Assignment Sheet, dated 3/5/19, states, in part: Has a history of masturbating. Keep blanket over lap. Resident is currently on one-on-one checks at all times. Initial. R1's Care Plan, Alteration in Thought Processes, dated 12/11/17, Problem (updated 10/14/18): Problem: Alteration in thought processes, resident observed taking frequent naps during AM shift; Patient requires reorient at meal times d/t (due to) dosing off (sic). No adverse medication effects noted or observed on this shift. Resident cooperative and friendly; no noted sexual comments/physical touching/grabbing. Continue to monitor. Notify MD (Medical Doctor) as necessary. Approach (12/11/17): .Record episodes of physical sexual grabbing, verbal sexual statements toward others, note changes and notify MD as needed, offer verbal cues, needs to be redirected when speaking in a sexual manner and moving toward females in MCU , take to room to offer private time, likes to visit and drink coffee with peers, encourage other conversation and give reading material that does not have women in it (looks at ads for women in bras, panties and gets him more restless), has videos available if needed, but have not been effective recently. Approach (12/11/17) Nurse Aide: Redirect and reorient resident when needed, take to room for privacy, offer conversation and try to divert conversation to other topics, encourage activity participation, arrange environment to meet resident's needs, offer reading material without pictures of women in it (ads with women in bras and panties have caused increase in behaviors at times) Offer conversation, provide one-on-one with resident, Use yes and no questions when speaking to the resident, Glasses on in AM and off at HS, Remove resident from activity/area if agitated. Take resident to a quiet place and provide one-on-one, (MONTH) need to go back and try to complete cares again. Goal: Safety maintained, Cooperative with cares, will have less than 5 episodes a day of sexual innuendo towards others, will have less than 2 episodes daily of attempts to grab at others, will have no adverse effects related to medication. Goal Time 11/5/18 (Three months). R1's Care Plan, History of Sensory Deprivation, dated 11/27/18, Problem: Exhibits socially inappropriate behavior as evidence by exposure and masturbation in public, Related to: Dementia, Manifested by: Hypersexuality. Nurses (11/27/18) - administer medications as ordered, cover lap with blanket for resident's privacy and dignity, divert resident from other female residents, videos available if needed. Nurse Aide (2/6/19) - maintain safety of resident and other residents, and other staff, Praise positives, keep resident covered with blanket for privacy and dignity, divert resident from female residents. Behavior Notes & Social Services Notes; 24 Hour Board documentation. 12/10/18 - Activity staff and CNAs report increased inappropriate approach and attempt to touch peers and staff. Res (resident) approached Activity Staff to touch staff buttocks, observed to approach female peer with extended middle finger to crotch of female peer. CNA reports res touching female staff inappropriately during cares. Res continues to try and take food from peers. 1/18/19 - Observed res to approach female peer x 2 (two times) with intent to touch sexually. Res attempting to place hand in female genital area. Staff intervened, res holding own genital area on outside of clothing. 1/18/19 24 Hour Board documentation - Obs (Observed) sexual approach toward female peers 1/21/19: Observed many approaches toward female peers with sexual intent. Res redirected by staff many times, res would then return to previous behavior. 1/21/19 24 Hour Board documentation - 1/21/19: MANY sexual approach to female peers - Needs close supervision and frequent redirection (See interview with CNA.-inappropriate sexual contact with 3 (possibly more) ladies this PM shift) 1/22/19: Res alert and mobile per w/c (wheelchair) on Unit. Res will stand independently, res continues to approach female peers with intent to touch females sexually. Res will place his hand between thighs of female peers that are clothed, res tries to massage the area he touches. Res redirected from this activity by staff, res will repeat behavior, needs frequent to constant supervision by staff. 1/22/19 24 Hour Board documentation - (PM Shift): Inappropriate approach toward female peers and touch 1/23/19: 24 Hour Board documentation - Inappropriate sexually - contact MD for med change ([MEDICATION NAME]) 1/24/19 - 24 Hour Board documentation: Standing up - sexual approach 1/28/19: Noted resident attempting to place hand on other residents, toileted and redirection done, will continue to monitor. 1/29/19: 24 Hour Board Documentation - Standing up - approaching female - ? Update MD d/t (due to) previous behavior resumed 2/2/19 (PM Shift): 24 Hour Board documentation - Inappropriate behavior with another female resident 2/3/19 (PM Shift): 24 Hour Board documentation - Inappropriate behavior with female resident 2/4/19: (PM Shift): 24 Hour Board documentation - Sexual behaviors touching women and himself 2/5/19: Staff is observing increased approach to female peers with sexual intent. Res redirected many times, greater than 10x (ten times), this shift. Res will approach females with middle finger extended, res will touch peers on clothing and along legs, abd (abdomen). After redirection, staff will offer TV, toileting, snack. Res observed to return previous behavior in short period of time. 2/5/19: (PM Shift): 24 Hour Board documentation - LOTS of approach sexually with touch to peer clothing - thighs - abdomen - legs - Tried intervention - Resident returned to behavior 2/6/19: 24 Hour Board documentation - Continues to approach female peers (Social Worker (SW) Note) 2/8/19: Late entry for 2/7/19: IDT (Interdisciplinary Team) reviewed behaviors and determined that it may be needed for resident to go to a behavioral health hospital and clinic for a short time to get medication regimen set up to decrease behaviors, but not make him lethargic. Placed call to Guardian to speak about getting approval to send a referral to a behavioral health hospital and clinic for this purpose. He states that he is 100% agreeing with the team's review and is fine with the referral sent over. He states that he only hopes R1 can return to us once his behaviors and medications have been balanced. This Writer agreed that this should only be for a short stay. Explained the process to Guardian for admission and what the team is doing in the time being to keep R1 and other residents safe. R1 is 1:1 to maintain his safety and the safety of other residents until this can be resolved. Placed call to a behavioral health hospital and clinic to ask about the admission and referral process. Intake SW sent over the referral list and a referral sent to her via fax. This Writer is awaiting a response. (Social Worker Note) 2/18/19: Late entry for 2/8/19: Spoke with R1's daughter after staff had asked if she or a family member could come to the facility to spend time with R1 to help assist with supervising him during this time period due to his behaviors. The behavioral health hospital and clinic has declined taking him, and the MD has put him back on [MEDICATION NAME]. The hope is that the behaviors will decrease without making him lethargic. Res daughter states that she does not have any family members or family friends in the area that could come spend time with R1 to assist in the supervision process. 2/10/19: 24 Hour Board documentation - Approaching females - no contact 2/11/19: Approached female resident and attempted to grab at her, family member intervened with no resident physical contact. (See interview with family member) 2/11/19: Staff intervention required between res and visitor today as res was approaching female peer while husband visited. Husband stated res tried to grab her. Staff redirected res from lounge area and visitor and wife. Observed res to approach female peers, offered toileting, rest and magazine to read. Interventions are minimally effective. (See interview with family member) 2/11/19: 24 Hour Board documentation - Approaching females - no touch 2/19/19: Observed res to approach with attempt to touch female peers in crotch repeatedly this shift. Staff redirected res from inappropriate behavior and offered TV, reading, mail or snack. Interventions are minimally effective. 2/19/19: 24 Hour Board documentation -Touching in inappropriate places - approaching female peers 3/2/19: (Night and AM Shift) 24 Hour Board documentation - Trying to grab crotch of several ladies 3/3/19: (PM Shift): 24 Hour Board documentation - Approaching female peers - redirected many x's (times) 3/6/19: Res continues to stand up independently and require staff direction to sit for safety, res did approach female peers with intent to touch x 2. Redirected by staff but res continues inappropriate approach. On 3/7/19, Surveyor observed R1, from 10:30 AM until 11:01 AM, in the activity area of the Unit R1 resides on. R1 was sitting with 7 female residents and 2 male residents in the activity area, with no staff in the area or within sight of the area. On 3/7/19 at 10:25 AM, Surveyor interviewed AD S (Activity Director). AD S stated R1 is on 15 minute checks, meaning staff are to have eyes on R1 at least every 15 minutes. AD S stated R1 is known to touch female residents. AD S does not have dedicated Activity Staff on R1's Unit at this time. On 3/7/19 at 4:30 PM, Surveyor interviewed R1's FM T (Family Member) via telephone. FM T is R1's Activated Healthcare Power of Attorney (AHCPOA). FM T stated he has only been called two to three times regarding incidents with R1 since 1/1/19. FM T stated he believed at least two of these calls were in regards to falls, only one was in regards to R1's sexual inappropriate behavior. On 3/7/19 at 5:15 PM, Surveyor interviewed SW V (Social Worker). SW V did know that R1 has a history of inappropriately touching female peers. SW V would expect staff to keep an eye on him, meaning redirect R1 away from female peers, keeping R1 within eyesight, not leaving him alone with female peers. SW V stated in February, 2019 R1 was given an intervention of one-on-one with staff because he was trying to touch female peer's thighs and legs. SW V could not remember any specific female peer whom R1 touched inappropriately. SW V does not remember when R1's one-on-one started or stopped. SW V stated the one-on-one was put into place by NHA A. Surveyor informed SW V of observation of R1 being left alone, unattended in a room with female peers on 3/7/19. SW V stated this should never have been done, R1 should have been under supervision when in a room with female peers. On 3/7/19 at 5:35 PM, Surveyor interviewed R1's FM U. FM U is R1's Alternate AHCPOA. FM U stated she had spoken with SW V, on 2/18/19, via telephone and was informed R1 was on one-on-one with staff at all times. Alternate AHCPOA stated she was under the understanding R1 was still one-on-one with staff at all times. On 3/7/19 at 10:30 AM, Surveyor spoke with RN F (Registered Nurse). RN F has been back on this Unit for 2 days and does not normally work on this Unit. RN F stated yesterday R1 was in his chair and was going over to a female. His middle finger was stuck out. RN F stated, That's the finger he uses. Surveyor asked RN F the finger he uses for what? RN F stated, I had seen him in somebody's vagina with his fingers. Surveyor asked RN F when did this happen. RN F stated in (YEAR). RN F stated R1 uses his middle finger to touch women in inappropriate places. RN F stated if R1 has his middle finger pointed forward, it shows his intent, and you need to intervene. Surveyor asked where RN F documents this behavior. RN F stated under Inappropriate Sexual Behavior in ECS (electronic computer system). RN F stated, They see that (Administration). RN F stated the previous DON D and previous NHA P, as well as current administration, is aware of his behaviors. RN F stated I don't know what they did. There was no meeting to discuss a plan for R1, nothing said, nothing done. We re-direct, get him involved in activities, keep an eye on him. RN F stated, I was sweating back here (on the MCU) to make sure this doesn't happen. RN F stated there is no 1:1, line of sight, or frequent checks (ie: 15 min). On 3/7/19 at 2:13 PM, Surveyor spoke with LPN C (Licensed Practical Nurse). Surveyor asked if LPN C works on MCU often. LPN C stated, Not often. Surveyor asked if LPN C if she has observed a resident touching another resident(s) inappropriately. LPN C stated, No, but it has been reported to me by our previous Act Dir K (Activities Director) or CNAs. It was usually R1 they were reporting. LPN C stated R1 was most recently reported to her at least 3 weeks ago, if not more. I can't remember who R1 touched. It was reported by the previous Act Dir K, but she quit. Surveyor asked if she recalled where he touched a resident? LPN C replied, Sometimes he touches on the leg, sometimes a hand, down a pant, but I don't remember the details. LPN C added, He has been caught various times. Surveyor asked LPN C if she reported the incident to the RN on duty, NHA A or DON B. LPN C stated, I honestly don't know anymore. Surveyor asked should it have been reported. LPN C stated, Yeah. Surveyor asked LPN C if she documents this info. LPN C stated, I at least put it on the 24 Hour Board. Surveyor asked have you ever written a statement or filed an incident report. LPN C replied, I don't know if I have or I haven't. Surveyor asked LPN C do you document in the woman's/victim's chart as well. LPN C stated, I don't think I've documented in there. LPN C stated, I just know what he's known for. LPN C stated, I've seen him go towards women and averted it by taking him away. When his medication was decreased, I'm hearing that it's (his behavior of touching other residents) happening more. LPN C stated, I heard he was touching somebody, had his hand in their shirt or under a blanket, nothing new, I haven't heard anything he hasn't done before. LPN C stated, When I hear the statements from other staff, it's either the breast or the crotch. Surveyor asked what women does he touch. LPN C stated, I think all of them. LPN C stated, I don't think he targets. He used to try to touch staff. Sure, the ones that can't move are going to be easier targets. Surveyor asked LPN C who has he touched in the past week. LPN C stated R6 or R18, but I'm not sure if I'm correct. (Note, no documentation on the 24 Hour Board documents the names of women being touched inappropriately.) LPN C stated, I don't think to ask if they were brought to the attention of management. Surveyor asked LPN C if R1 is under increased supervision. LPN C stated everybody has a habit of watching, due to his tendencies. Surveyor asked are residents afraid. R15 gets very upset and will yell, Get away from me! A lady (R16 or R17) yelled the last time, Get the hell away from me! His behavior upsets the residents. LPN C stated that the previous DON L informed her last week that reports are to be made. LPN C stated, R1's behavior prompted them, because his sexual behavior is increasing. Surveyor asked LPN C, so they (Administration) know about R1's behaviors. LPN C replied, Yeah. R1 came in with them, then didn't have them and now they've started up again. LPN C stated staffing at the facility is Terrible! We have a bunch of agency now; otherwise, we only have 3 CNAs for the building. LPN C stated for the past month our staffing has been horrible! LPN C stated that on the AM shift they would sometimes have only 3 CNAs for the AM shift, 2 CNAs until 4 PM, we usually only have 3, and 3 CNAs for the N[NAME] (night) shift. (Note the current census is 54.) Surveyor asked LPN C if R1 grabbed another resident's breast today, what would you do. LPN C stated, I would have to ask somebody what I should do. LPN C stated our Incident Report is geared toward injuries and falls. Surveyor asked LPN C would you tell anybody. LPN C would notify DON B. Surveyor asked LPN C how soon would you notify DON B. LPN C stated as soon as I could get to doing that; I can't drop everything. LPN C stated our previous Act Dir K had eagle eyes, she saw everything. She has been gone since 2/21/19. On 3/7/19 at 4:10 PM, Surveyor spoke with FM M (Family Member). FM M visits his wife almost every day for breakfast on the MCU. Surveyor asked FM M if he has observed any resident touch other resident(s) inappropriately. FM M stated there's only 1 resident and there's not much problem as long as he's watched. His name is R1, but he doesn't really know what he's doing. FM M stated, I've caught him several times, but I've taken him away from people (other residents). FM M stated I stop it when I see it happening. When I'm not there, I don't know what goes on. FM M stated he will always tell the nurse or CNA, after he removes R1, when he is inappropriately touching a female resident. FM M stated, He does reach and feel. FM M added, He sometimes puts his hands where they don't belong. I've seen him fondle multiple ladies. Surveyor asked if FM M knows the names of the ladies he has touched. FM M stated he doesn't know the residents' names. Surveyor asked FM M what area on the body he has observed R1 touching. FM M stated, On the breast or the leg, most of the time the ladies will push him away, but there's not many of the ladies that are aware. FM M stated he observed R1 grab R15's crotch once. FM M stated R15 yelled and let R1 know not to do that. FM M stated, I think it's something that the CNAs should watch more. FM M stated there was a point when there was only 1 CNA on duty with 1 Nurse. FM M stated, I only wish that the Act Dir K was here. I think they let her go. On 3/7/19 at 4:30 PM, Surveyor interviewed CNA H. Surveyor asked if CNA H if she has observed any resident touch other resident(s) inappropriately. CNA H stated, Yes, I have. CNA H continued, at supper time, the majority of residents are in their pajamas. CNA H stated that R1 targets ladies that are not with it and can't defend themselves. CNA H stated on 1/21/19 or 1/26/19 (The 24 Hour Board documentation confirms this occurred on 1/21/19) in the dining room at dinner. R1 went up to R19, whose arms are contracted, and put his hand between her body and arm and put his hand in her brief. CNA H removed R1's hand from the resident's brief and set him in the TV room. CNA H stated R1 made his way back into the dining room and came up to R20 and tried to touch her inappropriately. Surveyor asked CNA H where R1 touched R20. CNA H stated, More by her knee and making his way up (clarified to her thigh). CNA H put R1 back in the TV room. R1 came out of the TV room a second time and went to R14 and put his hand up her nightgown. CNA H stated R1 got his hand to her mid-thigh area. She stopped him by putting her hand on his so he could not move his hand any further. CNA H removed him again from the table in the dining room. CNA H set R1 at the end of the table and R14 was at the other end of the table. CNA H stated that R1 then started playing with himself in the dining room. After that, the other CNA working took him to his room and put him to bed. (Note, after R1 approached R19 and put his hand in her brief, he was removed from the dining room, but then returned 2 times during the meal to inappropriately touch 2 more residents (R20 and R14). After inappropriately touching R14, he was placed at a table across from R14 and then started playing with himself, before he was removed from the dining room.) Surveyor asked CNA H if staff check on R1 at certain intervals of time. CNA H stated we do not do any checks for R1 and no 1:1. CNA H stated they did not do any checks on R1 until after this happened. The checks only lasted for a few days. CNA H reported this to LPN N. CNA H stated DON D had me write a statement. CNA H stated (DON D) gave the statement to the NHA A. CNA H stated DON D and NHA A gave her the typed statement and she re-read it to make sure it was correct. Surveyor asked CNA H was it correct? CNA H stated, Yes. CNA H stated last week R1 reached for R17's crotch. CNA H stated, I told LPN C. Surveyor asked CNA H are any of the residents afraid of R1. CNA H stated, Not that I'm aware of. On 3/7/19 at 5:15 PM, Surveyor interviewed RN J. Surveyor asked if RN J has observed any resident touch other resident(s) inappropriately. RN J observed R1 with his hand in a female resident's private area. RN J clarified, Outside of pants on her crotch and he was Holding her there. She was not reacting. RN J immediately removed R1 far, far away, charted his behavior in the computer, just under his medical record, because she was the victim. Surveyor asked RN J did you report this to DON B or NHA A. RN J did not report it to the DON B or NHA A. RN J stated, I thought they knew already that this was going on. RN J stated a nurse needs to be back here at all times, due to the behaviors that go on. There's nobody watching residents that are still up, especially if I'm on a different Unit passing meds. RN J stated, tomorrow is my last day, because I can't stand to see our elderly treated this way. RN J stated that about 1-1 ½ months ago the physician had taken R1 off a med (medication) that inhibits sexual behavior and now R1 is back on the medication due to his behaviors. On 3/7/19 at 5:30 PM, Surveyor spoke with CNA I. CNA I stated, He grabs the women. Surveyor asked where does R1 grab the women. CNA I stated, In the private area and in the breasts. Surveyor asked what does CNA I do when this happens. CNA I separates them and tells them it is inappropriate. CNA I is unsure if there are any checks being done for R1. CNA I stated there was a paper in the charting room, for three weeks at most, and we don't do that any longer. Surveyor asked CNA I if R1 is on 1:1. CNA I stated, It depends on if there's an activity person here. CNA I stated that R1 is not on 1:1 supervision. This changed since Act Dir K left. We try to monitor R1, but don't write it down and he's not on 1:1. Surveyor asked CNA I how is the staffing at the facility. CNA I stated if there's 2 people on the MCU, it's ok, but if there's only 1 CNA and the nurse goes back and forth from MCU (300 Unit) to the 100 and 200 Units, then there's not enough staff. Surveyor asked CNA I are there things that don't get done as a result of not having enough staff. CNA I stated, Of course 1:1 time. CNA I stated R1 and R13 are both supposed to be on 1:1. Example 2 R13 is a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. R13's BIMS on 2/7/19 is 5 (Severe Cognitive Impairment) and he has a Legal Guardian. R13's CNA Assignment Sheet, dated 3/5/19, states, in part: that R13 transfers and ambulates independently without an assistive device. Special Care Remarks: Needs assist with ADL's (Activities of Daily Living) on AM and PM shift. Activity: sitting outside when the weather is nice, television, car, magazines, visiting, coloring, invite to activities: kickball, bean bag toss, dominoes, cards, trivia, UNO, . [MEDICATION NAME] N[NAME]s (at night) to apply early AM, PMs to remove and bedtime, does refuse to wear at times, use Dycem in lounge chairs to prevent resident from sliding out, encourage to sit with feet elevated, confused, report pain to nurse, . invite to activities: likes to sit and visit with peers over coffee and cookies. Does wander into other rooms, usually looking for bathroom. Redirect to his bathroom when able. R13 sometimes chooses to sleep in common areas in chairs or recliners. Encourage R13 to sleep in his bed in his room. If he chooses to fall asleep in a common area, redirect him to sleep in his bed in his room. R13's Care Plan, Alteration in Thought Processes, and mood/behavior changes, dated 2/21/19, Related to: Cognitive impairment, depression, anxiety, [MEDICAL CONDITION]. Manifested By: Difficulty with decision making, restlessness, fluctuating awareness. Approach .Has periods of time when he may be sexual in nature with his words and actions. Redirect behavior and encourage to participate in activities. Goal: Will have less than 8 episodes of negative statements a month, will have no physically aggressive episodes, will have no adverse effects related to medication regimen. Goal Time: 2/28/19. On 3/7/19 at 10:12 AM, Surveyor spoke with CNA E. CNA [NAME] usually works on the MCU. Surveyor asked if CNA [NAME] has observed any resident touch other resident(s) inappropriately. CNA [NAME] replied, yes, there was 1 incident I observed. CNA [NAME] stated it occurred approximately 2 weeks ago. R21 came to CNA [NAME] and said there was a husband and wife in R21's room. CNA [NAME] went to R21's room and it was not a husband and wife. It was R13 and R22. CNA [NAME] stated that R22 Is not really with it. CNA [NAME] observed R13 kissing R22 in R21's room. CNA [NAME] separated R13 and R22. CNA [NAME] stated that R13 is mobile and ambulates independently. CNA [NAME] stated that R22 did not seem upset. CNA [NAME] reported the incident to LPN C. CNA [NAME] stated when we see R13 by a female, we break them up, because I do feel he's thinking about it. CNA [NAME] stated when R22 first came to the facility (R22 was admitted [DATE]) they were found in a room together, but I'm not sure what they were doing. On 3/7/19 at 10:47 AM, Surveyor stepped into the Nurses Station and heard RN F start yelling. RN F started yelling and removed R13 from the TV room to the table right outside the TV room. RN F stated in a loud and frustrated voice, This is what I'm talking about! RN F stated R13 was in the TV room and RN F just observed him kissing R14. RN F stated she will call the physician and let DON B know. RN F stated DON B will let NHA A know. Surveyor asked, what about the family. RN F stated, yes, she will notify the family too. On 3/7/19 at 10:48 AM, Surveyor went into the TV room and spoke with R14. Surveyor asked R14 what just happened. R14 stated, He should shut up and stay away! Surveyor asked R14 how did it make you feel when R13 kissed you. R14 looked from side-to-side with a confused look on her face as she was thinking. R14 stated, Are you talking to me, bam! Are you saying R13 was talking to you and then all of a sudden he kissed you? R14 stated, Yes. R14 stated, I don't like that! Surveyor asked R14 if R13 has kissed you before. R14 stated, Yeah, I think so. Surveyor asked R14 do you know when he kissed you before. R14 stated, No. R14 stated, I didn't know what the hell was going on! Surveyor asked R14 does it bother you when R13 kisses you. R14 said, Yeah. Surveyor asked R14 do you feel safe. R14 stated, I didn't. Surveyor thanked R14 for sharing her feelings and exited the room. (It is important to note that the TV room has glass doors.) R13 was sitting at the table right outside the TV room, about 15-20 feet away from R14. Surveyor was standing outside of the TV room and observed R14 exit the TV room, approximately 1 minute after Surveyor left the TV room. R14 sat down at the table across from R13 and as she was sitting down she stated, Oh, that's scary! as she was looking at R13. On 3/7/19 at 11:02 AM, Surveyor exited the TV room after speaking with R14 and informed RN F that R14 does not feel safe following the incident that just occurred. (It is important to note that R14's BIMS is 2. Despite her severely impaired cognitive status, she was able to clearly relay to Surveyor that R13's physical contact was not only unwelcome, but it also made her feel shocked, angry, and unsafe.) On 3/7/19 at 11:55 AM, Surveyor spoke with NHA A to ensure that he was made aware of the incident between R13 and R14. NHA A stated he was just informed by DON B, right before he walked in his office to speak with us. Surveyor asked NHA A to see all investigations for R1 and R13. Surveyors asked NHA A how long he has been working at this facility. NHA A stated about 30 days. Surveyor asked NHA A what he knows about R13. NHA A stated he hasn't been here long and would need to look at R13's medical record. On 3/7/19 at 2:13 PM, Surveyor spoke with LPN C. Surveyor asked if LPN C has observed or if anybody has reported a resident kissing another resident. LPN C stated, I did have 1 resident (R13) kiss another resident (R22) last week. LPN C stated it was reported to me by an Activity person or an Aide. LPN C wrote it on the 24 Hour Board, at the end of the shift. I can't remember if I did an Incident Report or not. I know it's on the 24 Hour Board though, because I didn't know what to do with it. Surveyor asked LPN C if they notified the next shift. Did you report it to DON B or NHA A. LPN C stated,

Based on interview and record review, the facility did not ensure that the policy and procedures that prohibit mistreatment, abuse, and neglect of residents were implemented for 7 residents (R19, R20, R14, R15, R22, R6 and R18) with the potential to affect 16 females and 6 males on the Memory Care Unit (MCU) out of a total of 54 residents that reside in the facility. The facility did not immediately report allegations of abuse to the administrator and/or to the State Agency and investigate R19, R20, R14, R15, R22, R6 and R18), and did not fully investigate allegations of abuse and put measures in place to protect residents while an investigation was occurring (R19, R20, R14, R15, R22, R6 and R18). The failure of the facility to implement its abuse policy and procedure created a situation where further abuse occurred and could continue to occur led to the finding of Immediate Jeopardy (IJ), which started on 1/21/19. The facility was notified of the IJ on 3/11/19 at 11:10 AM. The IJ was removed on 3/7/19; however, the deficient practice continues at an [NAME] (potential for more than minimal harm that is not immediate jeopardy/pattern) as the facility continues to implement its removal plan. This is evidenced by: The facility's policy and procedure Resident Safety Abuse Policy, dated revised 9/17 (2), includes, in part: It is the policy of our facility to maintain a work and living environment that is professional and free from threat and/or occurrence of harassment, abuse (verbal, physical, mental or sexual), neglect, corporal punishment, involuntary seclusion, physical or chemical restraints not required to treat the resident's medical symptoms, exploitation and misappropriation of resident property. Providing a safe environment is one of the most basic and essential duties of the facility. Employees have a unique position of trust with vulnerable residents. Having access to private information, being in a physically intrusive position and having elevated status and special relationships with residents, makes ethical and professional behavior essential. Our facility promotes an atmosphere of sharing with residents and staff without fear of retribution. Residents have the right to be free from abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, visitors, friends, or other individuals. The system cannot guarantee that abuse will never occur. It can only assure that the facility is doing all that is within its control to prevent occurrences. Protocol: Federal Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury. C. Sexual Abuse is non-consensual sexual contact of any type with a resident. Determination of the resident's ability to consent must be determined. The most widely accepted criteria are: (1) knowledge of relevant information, including risks and benefits, (2) understanding or rational reasoning that reveals a decision that is consistent with the individual's values (competence) and (3) voluntariness (a stated choice without coercion). If the resident has the ability to consent and their representative disagrees about the resident engaging in sexual activity, the facility must honor the resident's wishes. i. Sexual abuse includes but is not limited to: 1. Unwanted intimate touching of any kind especially breasts or perineal area 2. All types of sexual assault or battery, such as rape, sodomy, and coerced nudity 3. Forced observation of masturbation and/pornography and . 6. Care and treatment of [REDACTED].>f. Staff members who observe a resident-to-resident abuse situation will immediately intervene and separate/remove the involved residents from the situation. Nursing staff will notify other shifts of the incident so they may be alert for the possibility of additional incidents. Immediate interventions will be initiated to attempt to eliminate the likelihood that the situation could recur. The facility IDT (Interdisciplinary Team) will care plan the resident/incident to discuss the situation and further develop possible approaches and interventions. If a resident's detrimental behavior persists, the IDT will care plan the resident again and determine which corrective actions will need to be taken (i.e. psychological assessment, alternative placement, implementation of the Unmanageable Residents Policy, etc.). 8. Reporting Suspected Violations a. The supervisor on duty shall IMMEDIATELY safeguard the resident(s) and immediately report all alleged violation involving abuse, neglect, mistreatment, exploitation, including injuries of unknown source and misappropriation of resident property to the facility administrator. The Administrator will notify the DON (Director of Nursing) and/or others as appropriate. b. The Administrator will report a reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from the facility, to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located. c. The Administrator shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. d. See Administrator Decision and Approval Process and Notification of Corporate Executive Management Personnel. Depending on the scope and severity of the incident, law enforcement may be called to immediately take over and direct the investigative process. In these situations, the Administrator needs to direct staff to treat the area like a crime scene, and not contaminate or destroy any evidence (i.e. giving the resident a shower, washing clothes or bedding, throwing items away, etc.). e. All facility staff members shall ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not results in serious bodily injury, to the Administration and the Administrator will ensure reporting to other officials (including to the State Survey Agency and adult protective service where state law provides jurisdiction in long-term care facilities) in accordance with state law. The facility did not prevent abuse Behavior Notes & Social Services Notes; 24 Hour Board documentation 12/10/18 - Activity staff and CNAs report increased inappropriate approach and attempt to touch peers and staff. Res (resident) approached Activity Staff to touch staff buttocks, observed to approach female peer with extended middle finger to crotch of female peer. CNA reports res touching female staff inappropriately during cares. Res continues to try and take food from peers. 1/18/19 - Observed res to approach female peer x 2 (two times) with intent to touch sexually. Res attempting to place hand in female genital area. Staff intervened, res holding own genital area on outside of clothing. 1/18/19 24 Hour Board documentation - Obs (Observed) sexual approach toward female peers 1/21/19: Observed many approaches toward female peers with sexual intent. Res redirected by staff many times, res would then return to previous behavior. 1/21/19 24 Hour Board documentation - 1/21/19: MANY sexual approach to female peers - Needs close supervision and frequent redirection 1/22/19: Res alert and mobile per w/c (wheelchair) on Unit. Res will stand independently, res continues to approach female peers with intent to touch females sexually. Res will place his hand between thighs of female peers that are clothed, res tries to massage the area he touches. Res redirected from this activity by staff, res will repeat behavior, needs frequent to constant supervision by staff. 1/22/19 24 Hour Board documentation - (PM Shift): Inappropriate approach toward female peers and touch 1/23/19: 24 Hour Board documentation - Inappropriate sexually - contact MD for med change ([MEDICATION NAME]) 1/24/19 - 24 Hour Board documentation: Standing up - sexual approach 1/28/19: Noted resident attempting to place hand on other residents, toileted and redirection done, will continue to monitor. 1/29/19: 24 Hour Board Documentation - Standing up - approaching female - ? Update MD d/t (due to) previous behavior resumed 2/2/19 (PM Shift): 24 Hour Board documentation - Inappropriate behavior with another female resident 2/3/19 (PM Shift): 24 Hour Board documentation - Inappropriate behavior with female resident 2/4/19: (PM Shift): 24 Hour Board documentation - Sexual behaviors touching women and himself 2/5/19: Staff is observing increased approach to female peers with sexual intent. Res redirected many times, greater than 10x (ten times), this shift. Res will approach females with middle finger extended, res will touch peers on clothing and along legs, abd (abdomen). After redirection, staff will offer TV, toileting, snack. Res observed to return previous behavior in short period of time. 2/5/19: (PM Shift): 24 Hour Board documentation - LOTS of approach sexually with touch to peer clothing - thighs - abdomen - legs - Tried intervention - Resident returned to behavior 2/6/19: 24 Hour Board documentation - Continue approach to female peers 2/10/19: 24 Hour Board documentation - Approaching females - no contact 2/11/19: Approached female resident and attempted to grab at her, family member intervened with no resident physical contact. 2/11/19: Staff intervention required between res and visitor today as res was approaching female peer while husband visited. Husband stated res tried to grab her. Staff redirected res from lounge area and visitor and wife. Observed res to approach female peers, offered toileting, rest and magazine to read. Interventions are minimally effective. 2/11/19: 24 Hour Board documentation - Approaching females - no touch 2/19/19: Observed res to approach with attempt to touch female peers in crotch repeatedly this shift. Staff redirected res from inappropriate behavior and offered TV, reading, mail or snack. Interventions are minimally effective. 2/19/19: 24 Hour Board documentation -Touching in inappropriate places - approaching female peers 3/2/19: (Night and AM Shift) 24 Hour Board documentation - Trying to grab crotch of several ladies 3/3/19: (PM Shift): 24 Hour Board documentation - Approaching female peers - redirected many x's (times) 3/6/19: Res continues to stand up independently and require staff direction to sit for safety, res did approach female peers with intent to touch x 2. Redirected by staff but res continues inappropriate approach. Per interview with CNA [NAME] (above), approximately 2 weeks ago, R13 was kissing R22 on the lips. On 3/7/19, R13 went up to a different resident, R14, and kissed her on the lips. R14 was visibly upset when this happened and was agitated and angry. (The facility did not prevent R13 from kissing more women, who are unable to consent, against their will.) On 3/7/19 at 4:10 PM, Surveyor spoke with FM M. FM M states that he has caught R1 touching both female and male residents several times and FM M stated he stops it (the abuse) when he sees it happening. FM M stated he will always tell the nurse or CNA, after he removes R1, when he is inappropriately touching a female resident. FM M stated, He does reach and feel. FM M added, He sometimes puts his hands where they don't belong. I've seen him fondle multiple ladies. FM M does not know the names of these female residents. FM M stated he has observed R1 touching female residents, On the breast or the leg, most of the time the ladies will push him away, but there's not many of the ladies that are aware. FM M stated he observed R1 grab R15's (a male) crotch once. FM M stated that R15 yelled and let R1 know not to do that. FM M stated, I think it's something that the CNAs should watch more. Staff did not report allegations of abuse On 3/7/19 at 10:12 AM, Surveyor spoke with CNA [NAME] (Certified Nursing Assistant). CNA [NAME] observed approximately 2 weeks ago, R13 kissing R22 on the lips while in R21's room. CNA [NAME] stated R22 Is not really with it. CNA [NAME] reported this incident to LPN C (Licensed Practical Nurse). On 3/7/19 at 2:13 PM, Surveyor spoke with LPN C. LPN C stated to Surveyor that last week it was reported to LPN C that R13 was kissing R22. LPN C stated this was reported by an Activity person or an Aide. There is no evidence that LPN C reported this to DON B or NHA A. The facility did not investigate this incident. As a result, another incident of sexual abuse occurred on 3/7/19 at 10:47 AM. On 3/7/19 at 10:30 AM, Surveyor spoke with RN F (Registered Nurse). RN F stated when incidents occur RN F charts them under Inappropriate Sexual Behavior in ECS (electronic computer system). RN F stated They see that. (Administration). RN F does not report the incidents directly to DON B or NHA A (Nursing Home Administrator). On 3/7/19 at 2:13 PM, Surveyor spoke with LPN C. LPN C stated, at least 3 weeks or more, it was reported to LPN C that R1 was inappropriately touching another resident, but does not remember who R1 was touching or where R1 was touching. LPN C stated it was reported to LPN C by our previous Act Dir K (Activity Director). LPN C doesn't recall if LPN C reported the sexual abuse. There is no evidence that LPN C reported the incident to DON B or NHA A. Staff did not prevent further instances of abuse or potential abuse According to the facility's abuse policy, noted above, f. Staff members who observe a resident-to-resident abuse situation will immediately intervene and separate/remove the involved residents from the situation. Nursing staff will notify other shifts of the incident so they may be alert for the possibility of additional incidents. Immediate interventions will be initiated to attempt to eliminate the likelihood that the situation could recur. Immediate interventions to eliminate the likelihood that a situation could recur did not occur in the following situations: On 3/7/19 at 4:30 PM, Surveyor spoke with CNA H. CNA H stated R1 targets ladies that are not with it and can't defend themselves. CNA H stated, on 1/21/19 or 1/26/19 (The 24 Hour Board documentation confirms this occurred on 1/21/19), R1 sexually abused 3 female residents during the dinner meal. CNA H stated R1 went up to R19, whose arms are contracted, and put his hand between her body and arm and put his hand in her brief. CNA H removed R1's hand from the resident's brief and set him in the TV room. CNA H stated R1 made his way back into the dining room and touched R20, more by her knee and making his way up (clarified to her thigh). CNA H put R1 back in the TV room. R1 came out of the TV room a second time and went to R14 and put his hand up her nightgown. CNA H stated R1 got his hand to her mid-thigh area. R14 stopped him by putting her hand on his so he could not move his hand any further. CNA H removed him again from the table in the dining room. CNA H set R1 at the end of the table and R14 was at the other end of the table. CNA H stated R1 then started playing with himself (masturbating) in the dining room. After that, the other CNA working, took R1 to his room and put him to bed. (Note, after R1 approached R19 and put his hand in her brief, he was removed from the dining room, but then returned 2 times during the meal to inappropriately touch 2 more residents (R20 and R14)). After inappropriately touching R14, R1 was placed at a table across from R14 and then started playing with himself before he was removed from the dining room. Despite having abused R19, the facility did not closely supervise R1. R1 was able to return to the dining room two more times and abuse other female residents. On 3/7/19 at 10:12 AM, Surveyor spoke with CNA [NAME] (Certified Nursing Assistant). CNA [NAME] stated, approximately 2 weeks ago, CNA [NAME] observed R13 kissing R22 on the lips while in R21's room. CNA [NAME] stated R22 Is not really with it. CNA [NAME] reported this incident to LPN C (Licensed Practical Nurse). On 3/7/19 at 2:13 PM, Surveyor spoke with LPN C. LPN C stated to Surveyor that last week it was reported to LPN C that R13 was kissing R22. LPN C stated this was reported by an Activity person or an Aide. LPN C did not report this to DON B or NHA A. The facility did not investigate this incident. As a result, another incident of sexual abuse occurred on 3/7/19 at 10:47 AM. On 3/7/19 at 10:47 AM, Surveyor stepped into the Nurses Station and heard RN F start yelling. RN F started yelling and removed R13 from the TV room to the table right outside the TV room. RN F stated in a loud and frustrated voice, This is what I'm talking about! RN F stated R13 was in the TV room and RN F just observed him kissing R14. RN F moved R13 to the table, right outside of the TV room, after observing R13 kissing R14. Surveyor spoke with R14 immediately after this incident. Surveyor asked R14 how did it make you feel when R13 kissed you. R14 looked from side-to-side with a confused look on her face as she was thinking. R14 stated, Are you talking to me, bam! Are you saying R13 was talking to you and then all of a sudden he kissed you? R14 stated, yes. R14 stated, I don't like that! Surveyor asked R14 has R13 kissed you before? R14 stated, Yeah, I think so. Surveyor asked R14 do you know when he kissed you before. R14 stated, No. R14 stated, I didn't know what the hell was going on! Surveyor asked R14 does it bother you when R13 kisses you. R14 said, Yeah. Surveyor asked R14 do you feel safe. R14 stated, I didn't. After Surveyor spoke with R14, R14 exited the TV room and sat at the table across from R13 and stated, Oh that's scary! while looking directly at R13. R13 and R14 were seated across from one another for approximately two minutes before staff notices and moved R13 to a different location. Despite having just kissed R14, the facility left R13 unsupervised and R13 and R14 remained in close proximity to each other for two minutes. On 3/7/19 at 6:30 PM, Surveyors spoke with at NHA A, DON B, and CC O (Corporate Consultant). NHA A stated R1 was not on 1:1 supervision. Surveyor asked if R1 is on increased behavior monitoring. NHA A stated we're not doing any increased behavior monitoring, not any more than we are doing for any other resident. CC O stated that due to the staffing shortage across the nation that no facility is able to provide 1:1. CC O further added that if any facility tells you they can provide 1:1 that they are s***ing you. Staff did not investigate allegations of abuse As noted above, FM M stated He (R1) sometimes puts his hands where they don't belong. I've seen him fondle multiple ladies. FM M stated he has observed R1 touching female residents, On the breast or the leg, most of the time the ladies will push him away, but there's not many of the ladies that are aware. FM M stated he observed R1 grab R15's (a male) crotch once. FM M stated he always reports these incidents to staff, either the RN, LPN or CNA when he would observe R1 inappropriately touching another resident. There is no evidence these allegations were investigated. On 3/7/19 at 6:30 PM, Surveyors spoke with at NHA A, DON B, and CC O (Corporate Consultant). Surveyor asked NHA A and DON B when he started working at this facility. NHA A stated 2/4/19 and DON B stated she started working here 2/11/19 and became the DON 3/6/19. NHA A stated there are no investigations for R1. Surveyor described the incidents that occurred 1/21/19 with R19, R20, and R14. NHA A stated he was not aware of any of these incidents. NHA A stated just because he's moving toward females does not mean he has a sexual intent; he may just be saying hello. NHA A stated, Is it a sexual behavior or perception of staff, due to a history of perceived behaviors? Surveyor asked NHA A if he was aware of any behaviors for R13. NHA A stated apart from what was reported today, no. NHA A stated there are no investigations for R13. DON B stated she is not aware that he has a history of going up and kissing women. Surveyor shared the incident reported by LPN C. NHA A and DON B was unaware of this incident and NHA A stated he has no investigations for R13. NHA A stated he did not know that R13 had a history of [REDACTED]. The facility did not report allegations of abuse to law enforcement On 3/7/19 at 10:12 AM, Surveyor spoke with CNA [NAME] (Certified Nursing Assistant). CNA [NAME] stated, approximately 2 weeks ago, CNA [NAME] observed R13 kissing R22 on the lips while in R21's room. CNA [NAME] stated R22 Is not really with it. CNA [NAME] reported this incident to LPN C (Licensed Practical Nurse). The facility did not report this to local law enforcement within 2 hours. On 3/7/19 at 2:13 PM, Surveyor spoke with LPN C. LPN C stated, at least 3 weeks or more, it was reported to LPN C, by the previous Act Dir K (Activity Director), that R1 was inappropriately touching another resident, but does not remember who R1 was touching. The facility did not report this to local law enforcement within 2 hours. On 3/7/19 at 2:13 PM, Surveyor spoke with LPN C. LPN C stated last week it was reported to LPN C that R13 was kissing R22. The facility did not report this to local law enforcement within 2 hours. On 3/7/19 at 2:13 PM, Surveyor spoke with LPN C. LPN C stated, When I hear statements from other staff regarding R1 and where he is touching women, it's either the breast or the crotch. Surveyor asked what women does he touch. LPN C stated, I think all of them. LPN C stated, I don't think he targets. He used to try to touch staff. Sure, the ones that can't move are going to be easier targets. Surveyor asked LPN C who has he touched in the past week? LPN C stated R6 or R18, but I'm not sure if I'm correct. The facility did not report these incidents to local law enforcement within 2 hours. On 3/7/19 at 10:47 AM, during the complaint investigation, RN F (Registered Nurse) observed R13 kissing R14 on the lips in the TV room. RN F separated the residents and contacted DON B, who reported the incident to NHA A (Nursing Home Administrator). The facility did not report this to local law enforcement within 2 hours. On 3/7/19 at 4:30 PM, Surveyor spoke with CNA H. CNA H stated that R1 targets ladies who are not with it and can't defend themselves. CNA H stated, on 1/21/19 or 1/26/19 (The 24 Hour Board documentation confirms this occurred on 1/21/19), R1 sexually abused 3 female residents during the dinner meal. The facility did not report this to local law enforcement within 2 hours. (See above). The failure to implement its policies and procedures to ensure that residents were free from abuse created a finding of IJ. The facility removed the jeopardy on 3/7/19 when it began implementing the following: Starting 3/7/19 at 8:30 PM, the Administrator and/or designee will educate facility staff prior to the start of their next scheduled shift on the facility Resident Safety Abuse Policy with emphasis on the following: -All residents have the right to be free from any form of abuse. Residents at this facility are a very at-risk and vulnerable population. -Abuse definitions and what constitutes abuse as defined in the Abuse Policy. -Staff has the duty to protect all residents from any form of abuse. -If any abuse or suspicion of abuse is noted, the staff will immediately stop the abuse and protect the resident. The staff will also assure that actions taken will protect all other residents as well. Staff will then immediately report any abuse or suspicion of abuse to their supervisor who MUST report to the DON and/or Administrator who will report within 2 hours to the state agency and Law Enforcement. -Within two hours, staff is required to immediately report to Law Enforcement the reasonable suspicion of a crime where there is abuse or bodily harm. -All allegations of abuse will be immediately investigated and the abuse policy followed. -Sexual behavior intervention training. On 3/7/19 at 9:00 AM, the Interdisciplinary Team will be educated by the Administrator on the facility Resident Safety Abuse Policy with emphasis on the following: -All residents have the right to be free from any form of abuse. Resident at the facility are a very at-risk and vulnerable population. -Abuse definitions and what constitutes abuse as defined in the Abuse Policy. -Staff has the duty to protect all residents from any form of abuse. -If any abuse or suspicion of abuse is noted, the staff will immediately stop the abuse and protect the resident. The staff will also assure that actions taken will protect all other residents as well. Staff will then immediately report any abuse or suspicion of abuse to their supervisor who MUST report to the DON and/or Administrator who will report within 2 hours to the state agency and Law Enforcement. -Within two hours, staff is required to immediately report to Law Enforcement the reasonable suspicion of a crime where there is abuse or bodily harm. -All allegations of abuse will be immediately investigated and the abuse policy followed. Sexual behavior intervention training -R1 and R13 were placed on increased supervison as of 3.7.19. -R1 and R13 are seated at the same table during dinning services with a male peer as 0f 3.7.19. Cross reference F600 Cross reference F605 Cross reference F609. Cross reference F610.

Based on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation or mistreatment all alleged violations were thoroughly investigated, and that steps were taken to prevent further potential abuse for 7 residents (R19, R20, R14, R15, R22, R6 and R18) with the potential to affect 16 females and 6 males on the Memory Care Unit (MCU) out of a total of 54 residents that reside in the facility. The failure of the facility to implement its abuse policy and procedure created a situation where further abuse occurred and could continue to occur. This led to the finding of Immediate Jeopardy (IJ), which started on 1/21/19. The facility was notified of the IJ on 3/11/19 at 11:10 AM. The facility removed the jeopardy on 3/7/19; however, the deficient practice continues at a scope/severity level of [NAME] as the facility continues to implement its removal plan. Findings include: The facility's policy and procedure, Resident Safety Abuse Policy,dated revised 9/17 (2), includes, in part: Protocol: Federal Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury. C. Sexual Abuse is non-consensual sexual contact of any type with a resident. Determination of the resident's ability to consent must be determined. The most widely accepted criteria are: (1) knowledge of relevant information, including risks and benefits, (2) understanding or rational reasoning that reveals a decision that is consistent with the individual's values (competence) and (3) voluntariness (a stated choice without coercion). If the resident has the ability to consent and their representative disagrees about the resident engaging in sexual activity, the facility must honor the resident's wishes. i. Sexual abuse includes but is not limited to: 1. Unwanted intimate touching of any kind especially breasts or perineal area 2. All types of sexual assault or battery, such as rape, sodomy, and coerced nudity 3. Forced observation of masturbation and/pornography and . 6. Care and treatment of [REDACTED].>f. Staff members who observe a resident to resident abuse situation will immediately intervene and separate/remove the involved residents from the situation. Nursing staff will notify other shifts of the incident so they may be alert for the possibility of additional incidents. Immediate interventions will be initiated to attempt to eliminate the likelihood that the situation could recur. The facility IDT will care plan the resident/incident to discuss the situation and further develop possible approaches and interventions. If a resident's detrimental behavior persists, the IDT will care plan the resident again and determine which corrective actions will need to be taken (i.e. psychological assessment, alternative placement, implementation of the Unmanageable Residents Policy, etc.). 8. Reporting Suspected Violations a. The supervisor on duty shall IMMEDIATELY safeguard the resident(s) and immediately report all alleged violation involving abuse, neglect, mistreatment, exploitation, including injuries of unknown source and misappropriation of resident property to the facility administrator. The Administrator will notify the DON and/or others as appropriate . e. All facility staff member shall ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not results in serious bodily injury, to the Administration and the Administrator will ensure reporting to other officials (including to the State Survey Agency and adult protective service where state law provides jurisdiction in long-term care facilities) in accordance with state law. The facility uses 24 Hour Board documentation to report information about residents to oncoming shifts. Information on the 24 Hour Board concerning R1 includes: 1/21/19. MANY sexual approach to female peers - Needs close supervision and frequent redirection 1/22/19. Inappropriate approach toward female peers and touch 2/2/19. Inappropriate behavior with another female resident 2/3/19. Inappropriate behavior with female resident 2/4/19. Sexual behaviors touching women and himself 2/5/19 (PM shift): LOTS of approach sexually with touch to peer clothing - thighs - abdomen - legs - Tried intervention - Resident returned to behavior 2/19/19: Touching in inappropriate places - approaching female peers 3/2/19: (Night and AM Shift) - Trying to grab crotch of several ladies 3/3/19: (PM Shift): - Approaching female peers - redirected many x's (times) There is no evidence that allegations of abuse identified on this board were communicated to the administrator, that the administrator investigated, and that measures were put in place to prevent further potential abuse. On 3/7/19 at 10:12 AM, Surveyor spoke with CNA [NAME] (Certified Nursing Assistant). CNA [NAME] stated, approximately 2 weeks ago, CNA [NAME] observed R13 kissing R22 on the lips while in R21's room. CNA [NAME] stated R22 Is not really with it. CNA [NAME] reported this incident to LPN C (Licensed Practical Nurse). On 3/7/19 at 2:13 PM, Surveyor spoke with LPN C. LPN C stated to Surveyor that last week it was reported to LPN C that R13 was kissing R22. LPN C stated this was reported by an Activity person or an Aide. LPN C did not report this to DON B or NHA A. The facility did not investigate this incident. As a result, another incident of sexual abuse occurred on 3/7/19 at 10:47 AM (below.) On 3/7/19 at 10:47 AM, during the complaint investigation, RN F observed R13 kissing R14 on the lips in the TV room. RN F separated the residents and contacted DON B, who reported the incident to NHA A. LPN C's failure to report the previous incident of R13 kissing R22, allowed sexual abuse to continue on the MCU. RN F moved R13 to the table right outside of the TV room after observing R13 kissing R14. Surveyor spoke with R14 immediately after this incident. Surveyor asked R14 how it made her feel when R13 kissed her. R14 looked from side-to-side with a confused look on her face as she was thinking. R14 stated, Are you talking to me, bam! Are you saying R13 was talking to you and then all of a sudden he kissed you? R14 stated, Yes. R14 stated, I don't like that! Surveyor asked R14 if R13 has kissed you before. R14 stated, Yeah, I think so. Surveyor asked R14 do you know when he kissed you before. R14 stated, No. R14 stated, I didn't know what the hell was going on! Surveyor asked R14 does it bother you when R13 kisses you. R14 said, Yeah. Surveyor asked R14 do you feel safe. R14 stated, I didn't. After Surveyor spoke with R14, R14 exited the TV room and sat at the table across from R13 and stated, Oh that's scary! while looking directly at R13. R13 and R14 were seated across from one another for approximately 2 minutes before staff noticed and moved R13 to a different location. The facility failed to prevent further potential abuse by allowing R13 and R14 to sit at a table across from one another immediately after this incident of sexual abuse occurred. On 3/7/19 at 10:30 AM, Surveyor spoke with RN F (Registered Nurse). RN F stated when incidents occur RN F charts them under Inappropriate Sexual Behavior in ECS (electronic computer system). RN F stated, They see that. (Administration) RN F does not report the incidents directly to DON B (Director of Nursing) or NHA A (Nursing Home Administrator). On 3/7/19 at 2:13 PM, Surveyor spoke with LPN C. LPN C stated, at least 3 weeks or more, it was reported to LPN C, by the previous Act Dir K (Activity Director), that R1 was inappropriately touching another resident, but does not remember who R1 was touching or where R1 was touching. LPN C doesn't recall if LPN C reported the sexual abuse. There is no evidence that the incident was reported or investigated. On 3/7/19 at 2:13 PM, Surveyor spoke with LPN C. LPN C stated, When I hear statements from other staff regarding R1 and where he is touching women, it's either the breast or the crotch. Surveyor asked what women he touches. LPN C stated, I think all of them. LPN C stated, I don't think he targets. He used to try to touch staff. Sure, the ones that can't move are going to be easier targets. Surveyor asked LPN C who has he touched in the past week? LPN C stated R6 or R18, but I'm not sure if I'm correct. LPN C stated that R15 gets very upset and will yell Get away from me! (Note, per interview with FM M (Family Member) (below), FM M stated he observed R1 grab R15's crotch once. A lady (R16 or R17) yelled the last time, Get the hell away from me! His behavior upsets the residents.) LPN C stated that the previous DON L informed LPN C last week that reports are to be made. LPN C stated, R1's behavior prompted them, because his sexual behavior is increasing. There is no evidence that these incidents were reported or investigated. On 3/7/19 at 4:10 PM, Surveyor spoke with FM M. FM M states he has caught R1 touching both female and male residents several times and FM M stated he stops it (the abuse) when he sees it happening. FM M stated he will always tell the nurse or CNA, after he removes R1, when he is inappropriately touching a female resident. FM M stated, He does reach and feel. FM M added, He sometimes puts his hands where they don't belong. I've seen him fondle multiple ladies. FM M does not know the names of these female residents. FM M stated he has observed R1 touching female residents, On the breast or the leg, most of the time the ladies will push him away, but there's not many of the ladies that are aware. FM M stated he observed R1 grab R15's (a male) crotch once. FM M stated that R15 yelled and let R1 know not to do that. FM M stated, I think it's something that the CNAs should watch more. FM M stated he always reports these incidents to staff, either the RN, LPN or CNA. There is no evidence these incidents were investigated or that measures were put in place to prevent further abuse. On 3/7/19 at 4:30 PM, Surveyor spoke with CNA H. CNA H stated R1 targets ladies that are not with it and can't defend themselves. CNA H stated, on 1/21/19 or 1/26/19 (The 24 Hour Board documentation confirms this occurred on 1/21/19), that R1 sexually abused 3 female residents during the dinner meal. CNA H stated R1 went up to R19, whose arms are contracted, and put his hand between her body and arm and put his hand in her brief. CNA H removed R1's hand from the resident's brief and set him in the TV room. CNA H stated R1 made his way back into the dining room and touched R20, more by her knee and making his way up (clarified to her thigh). CNA H put R1 back in the TV room. R1 came out of the TV room a second time and went to R14 and put his hand up her nightgown. CNA H stated R1 got his hand to her mid-thigh area. She stopped him by putting her hand on his so he could not move his hand any further. CNA H removed him again from the table in the dining room. CNA H set R1 at the end of the table and R14 was at the other end of the table. CNA H stated R1 then started playing with himself (masturbating) in the dining room. After that, the other CNA working, took R1 to his room and put him to bed. (Note, after R1 approached R19 and put his hand in her brief, he was removed from the dining room, but then returned 2 times during the meal to inappropriately touch 2 more residents (R20 and R14). After inappropriately touching R14, he was placed at a table across from R14 and then started playing with himself before he was removed from the dining room.) CNA H reported this to LPN N. CNA H stated DON D (previous Director of Nursing) had me write a statement. CNA H stated (DON D) gave the statement to the NHA A (Nursing Home Administrator). CNA H stated DON D and NHA A gave the typed statement to CNA H to re-read to make sure it was correct. Surveyor asked CNA H was it correct? CNA H stated, Yes. There is no evidence that LPN N reported this to DON B or NHA A when informed by CNA H. The facility did not protect its most vulnerable residents from sexual abuse and investigate the incidents of sexual abuse. The failure to ensure that allegations of abuse were reported and investigated and that staff implemented measures to prevent further potential abuse created a finding of immediate jeopardy. The facility removed the jeopardy on 3/7/19 when: Starting 3/7/19 at 8:30 PM, the Administrator and/or designee began educating facility staff prior to the start of their next scheduled shift on the facility Resident Safety Abuse Policy with emphasis on the following: -All residents have the right to be free from any form of abuse. Residents at this facility are a very at-risk and vulnerable population. -Abuse definitions and what constitutes abuse as defined in the Abuse Policy. -Staff has the duty to protect all residents from any form of abuse. -If any abuse or suspicion of abuse is noted, the staff will immediately stop the abuse and protect the resident. The staff will also assure that actions taken will protect all other residents as well. Staff will then immediately report any abuse or suspicion of abuse to their supervisor who MUST report to the DON and/or Administrator will report within 2 hours to the state agency and Law Enforcement. -Within two hours, staff is required to immediately report to Law Enforcement the reasonable suspicion of a crime where there is abuse or bodily harm. -All allegations of abuse will be immediately investigated and the abuse policy followed. -Sexual behavior intervention training. On 3/7/19 at 9:00 AM, the Interdisciplinary Team will be educated by the Administrator on the facility Resident Safety Abuse Policy with emphasis on the following: -All residents have the right to be free from any form of abuse. Resident at the facility are a very at-risk and vulnerable population. -Abuse definitions and what constitutes abuse as defined in the Abuse Policy. -Staff has the duty to protect all residents from any form of abuse. -If any abuse or suspicion of abuse is noted, the staff will immediately stop the abuse and protect the resident. The staff will also assure that actions taken will protect all other residents as well. Staff will then immediately report any abuse or suspicion of abuse to their supervisor who MUST report to the DON and/or Administrator who will report within 2 hours to the State Agency and Law Enforcement. -Within two hours, staff is required to immediately report to Law Enforcement the reasonable suspicion of a crime where there is abuse or bodily harm. -All allegations of abuse will be immediately investigated and the abuse policy followed. -Sexual behavior intervention training.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all 56 residents. Kitchen staff were not testing the parts per million of the low temperature chemical sanitizing dishwasher during a Norovirus outbreak. Therefore staff was not ensuring that kitchenware was being properly sanitized. On [DATE], the test strip did not change colors because the injector was clogged. Juice, milk and tea was not dated and expired. Powdered milk was stored with a scoop inside the container. Findings include: Example 1 Failure to ensure systems was in place to prevent the continued spread of a Norovirus outbreak created a finding of Immediate Jeopardy (IJ). The IJ began on [DATE]. NHA A (Nursing Home Administrator) was officially notified of the IJ on [DATE] at 4:00 PM. The facility removed the IJ on [DATE]. However, the deficient practice continues at a scope/severity level F (no actual harm with potential for more than minimal harm that is not IJ/widespread) as the facility continues to implement its removal plan and as evidenced by: The facility uses the US Food Code as their kitchen's operational standards of practice. 2017 Food and Drug Administration (FDA) Food Code states: ,[DATE].14 Sanitizing Solutions, Testing Devices: A test kit or other device that accurately measures the concentration in MG/L of sanitizing solutions shall be provided. ,[DATE].116 Warewashing Equipment, Determining Chemical Sanitizer Concentration: Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. ,[DATE].116 Warewashing Equipment, Determining Chemical Sanitizer Concentration: The effectiveness of chemical sanitizers is determined primarily by the concentration and pH (scale of acidity) of the sanitizer solution. Therefore, a test kit is necessary to accurately determine the concentration of the chemical sanitizer solution. ,[DATE].10 Food-Contact Surfaces and Utensils: Utensils shall be sanitized. ,[DATE].14 Sanitizing Solutions, Testing Devices: Testing devices to measure the concentration of sanitizing solutions are required for 2 reasons: 1. The use of chemical sanitizers requires minimum concentrations of the sanitizer during the final rinse step to ensure sanitization; and 2. Too much sanitizer in the final rinse water could be toxic. The facility policy titled Dish Machine--Low Temperature/Chemical Status Procedure states: Purpose: To provide consistent, accurate recordings of dish machine temperatures and chemical status and ensure appropriate function of low temperature dish machine equipment. Protocol: 1. Recording of dish machine temperatures: Check the temperatures by using the external gauge located on the dish machine .Dish machine wash/rinse cycle temperatures can be no less than 120 degrees F and no greater than 160 degrees F or per dish machine manufacturer specifications. 2. Recording of Chlorine PPM (Parts per Million) test: a. Run the dish machine for one complete cycle. b. When the machine goes into the rinse cycle, it pumps in the chlorine sanitizer; this solution is not drained from the machine but becomes the water for the wash cycle during the next load. c. Dip one strip of chlorine test paper into solution in dish machine. d. Leave test paper in solution for one second. Do not agitate or swirl the test paper. e. Blot test paper with paper towel to remove excess water. f. Immediately compare to color chart on test paper container and record this number on the Low Temperature/Chemical Status Dish Machine Chart. g. Chlorine PPM can be no less than 50 PPM and no greater than 100 PPM or per chemical manufacturer specifications. 3. If you record a temperature or chlorine PPM that is not within the limits shown, you must fix the problem immediately and record on the temperature sheet what you did to fix the problem. 4. If you get a temperature or chlorine PPM out of parameters, immediately try one or more of the following before you record the temperature or chlorine PPM: a. Drain the water from the dish machine and refill. b. Run one cycle with no dishes in the machine. 5. If the temperature or chlorine PPM is still out of normal range, do not use the dish machine and contact maintenance or the dietary manager immediately for further action. On [DATE], one resident on the 300 Wing developed infectious symptoms of nausea and diarrhea. The next day, [DATE], nine additional residents on all three Wings became ill with similar symptoms (2 on 100 Wing, 4 on 200 Wing, and 3 on 300 Wing) as did one staff person. The facility identified that an outbreak had occurred and began implementing precautions according to their Infection Control Program. The facility also notified public health and their medical director, who ordered stool samples. The facility was unable to get a stool sample until [DATE], and it tested positive for Norovirus. Residents continued getting ill even after the facility implemented precautions on [DATE]. The following illnesses occurred: [DATE]: 3 residents on 300 Wing became ill. [DATE]: 1 resident on 300 Wing became ill. [DATE]: 2 residents on 300 Wing and 2 residents on 100 Wing became ill. Ten staff called in ill. On [DATE], the facility identified breaks in the proper use of using personal protective equipment (PPE) and handwashing and all staff were retrained on [DATE]. Illnesses continued as follows: [DATE]: 5 staff called in ill, including 2 in the Dietary Department. [DATE]: 1 resident on 200 Wing became ill. [DATE]: 1 resident on 100 Wing became ill. [DATE]: 1 resident on 200 Wing became ill. [DATE]: 3 additional residents became ill, one on each Wing. [DATE]: 1 resident on 200 Wing became ill. [DATE]: 2 residents on 300 Wing became ill. [DATE]: 1 resident on 300 Wing became ill. On [DATE], Surveyors observed one CNA (Certified Nursing Assistant) fail to use PPE when entering the rooms of two ill residents. They also observed one staff fail to wash/sanitize hands during wound care. On [DATE], 1 resident on 200 Wing became ill. In total, 29 of 56 residents (52%) have become ill and 32 staff have become ill. No residents required hospitalization . (Cross-reference F880.) The facility leases its dishwasher and maintenance is completed by a contracted maintenance company. Facility Maintenance Logs indicate the contracted maintenance company had been to the facility on [DATE] and performed work on the Dishwasher Conveyor. At that time, the Maintenance Log, signed by CM M (Contracted Maintenance), indicated the dishwasher was inspected and the PPM of the dishwasher tested at 100 PPM. Facility logs titled Dish Machine--Low Temperature/Chemical Status Chart, dating back to (MONTH) (YEAR), show the facility documented the dishwasher wash and rinse temperatures three times per day. However, no PPM was recorded in (MONTH) through December, contrary to facility policies and procedures. September's PPM recording areas were blank, whereas October, (MONTH) and December's PPM recording areas were crossed out. The chart states, at the bottom, **Chlorine PPM: No less than 50 PPM and no greater than 100 PPM or per the chemical manufacturer specifications. On [DATE] at 9:12 AM, Surveyor observed DA J (Dietary Aide) washing dishes with the facility's dishwasher. Surveyor asked DA J to test the PPM of the dishwasher. DA J took a test strip and dipped it into the water for 2 seconds and pulled it out. The strip did not change color and remained its original white color. ,[DATE] PPM would change the test strip paper to a purple-like color. DA J then stated, a few weeks ago one of the tubes connecting to the sanitizer began to spray everywhere. The facility called in the contracted maintenance company. DA J stated that since that time, the test strips have not been changing colors. At 9:30 AM, DA J attempted to once again test the water inside the dishwasher. The test strip, again, did not change color and the test strip remained its original white color. DA J stated, I don't think he fixed it and pointed to the bottle of sanitizer that is supposed to flow from its mounted position on the wall to the dishwasher. DA J then stated,See, it's full. Nothing is coming out. On [DATE] at 10:20 AM, Surveyor interviewed DA K, along with DM L (Dietary Manager). DA K stated DA K ran a test strip through about a week ago after maintenance had already been to the facility and the strips were not testing correctly. DA K had notified DM L at that time. DM L doesn't remember DA K speaking with DM L and had not spoken with the contracted maintenance company since [DATE]. At 10:30 AM, Surveyor observed DA K test the dishwasher PPM two more times, once in the sitting water at the bottom of the dishwasher and once on a tray that had just run through the dishwasher. In both cases, the test strip failed to change colors and remained its original white color. Then, DM L attempted a final time to get the correct PPM, which failed to change the color of the test strip. On [DATE] at 2:10 PM, DM L, along with NHA A (Nursing Home Administrator), ANHA C (Assistant Nursing Home Administrator), DA J, and DA K requested to speak with Surveyors. CM M was present. DM L stated CM M came to the facility a few months ago and talked to the kitchen staff about recording of dishwasher temperatures and that was all they needed for the state. According to DM L, CM M showed staff how to check PPM, but told staff they did not need to use the test strips, which is why they were not collecting the PPM. CM M stated this was not true. CM M stated that when he spoke with kitchen staff a few months ago, he was only confirming the correct temperatures that were needed in accordance with the manufacturer's recommendations of achieving temperatures between 120 and 160 degrees Fahrenheit, but did not tell staff they were not required to test the chemical sanitization PPM. The facility removed the IJ on [DATE] when: On [DATE] at 2:46 PM, Surveyor observed the dishwasher test at the correct PPM. CM M stated the injector, which connects the tube running from the sanitizer to the entrance point of the dishwasher, had been clogged and was not allowing sanitizer to flow into the dishwasher. The deficient practice continues at a scope/severity of F (potential for no more than minimal harm that is not immediate jeopardy/widespread) as evidenced by: Example 2 On [DATE] at 10:31 AM, Surveyor observed the following in the facility main kitchen's: 4 1-gallon milks (2 chocolate, 1 2% and 1 skim) opened with no open dates, 1 gallon of skim milk unopened with an expiration date of (MONTH) 16, (YEAR), a one quart pitcher of iced tea with no open or prep date, and 10 frozen juice boxes (64 oz, 6 orange, 4 apple) with no expiration or thaw dates. Example 3 On [DATE] at 10:31 AM, Surveyor observed a container of dried milk powder with a serving spoon inside the milk powder, half exposed. On [DATE] at 10:45 AM, Surveyor interviewed DM L. DM L stated the milk, juice, and tea should have expiration dates, open dates and thaw dates. DM L also stated the container of milk powder should not have a serving spoon in it as it is an infection control risk.

Based on observation, interview and record review, the facility did not ensure a resident receives care consistent with professional standards of practice, to prevent development of pressure injuries (PI) unless clinically contradicted and residents with PIs receive treatment and services consistent with professional standards of practice, for 2 of 2 residents with PIs out of a total sample of 26 residents (R6 & R34). R6 developed an unstageable PI to the coccyx. There were no order changes when the pressure injury was first identified on 1/4/18 as being a stage 2. Two weeks later the wound was a stage 3. Subsequent documentation shows inconsistent staging and not having consistent weekly measurements. Surveyor had observations of staff not following the care plan. R6's mattress is only good for up to a stage II PI, yet R6 remained on this mattress. R6 had a stage II PI to neck and no measurements were provided. R34 was admitted to the facility without a PI and was identified to be at risk for PI development. R34 developed a Stage 2 PI, which progressed to a Deep Tissue PI (DTPI) and then to an unstageable PI. The facility failed to do weekly assessments, correctly identify PI, and ensure that care plan interventions were followed resulting in PI worsening. This is evidenced by: Facility Policy entitled Skin Care Management, with review date of 6/2017, states, in part: It is the policy of this nursing home to provide skin care to residents that includes assessment, prevention of skin breakdown and management of PI and other skin integrity concerns. Protocol: .2. The Skin and Body Assessment Form is to be completed as instructed above at the time of admission, quarterly, and if there is a significant change in the residents condition, acuity or alterations to skin .a. If any pressure or other skin ulcers are found during an assessment the Skin Care Flow Sheet (or electronic equivalent) is to be completed and maintained until the area is healed and for 30 days after. If paper-based, all assessments are to be filed in the assessment section of the medical record when completed.8. The Skin Care Flow Sheets will be reviewed through PAR (Performance Annual Review) and through the QAPI (Quality Assurance and Performance Improvement) Committee and any change in care, treatment, nutritional support, etc. will be determined and documented. The care plan will be reviewed and updated as appropriate by the Interdisciplinary Team (IDT). Skin Treatment Management Guidelines .Stage 1 PI non-blanchable [DIAGNOSES REDACTED] of intact skin.Stage 2 PI: Partial thickness skin loss with exposed dermis. 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.Stage 3 PI: Full-thickness skin loss, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; .if slough or eschar obscures the extend of tissue loss this is an Unstageable PI.Treatment Guidelines: .Re-evaluate bed and wheelchair surfaces. Re-evaluate/implement prevention interventions. Update care plan/C.N.A. (Certified Nursing Assistant) Assignment Sheet.Stage 4 PI: 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 . Unstageable PI: 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 PI will be revealed. Treatment guidelines: .Weekly re-assessment and documentation through end of healing plus 4 weeks.DTPI: persistent non-blanchable deep red, maroon or purple discoloration . Example 1: R6 was admitted on [DATE] with [DIAGNOSES REDACTED]. R6's Quarterly MDS (Minimum Data Set), dated 12/24/2017, indicates the following: BIMS (Brief Interview of Mental Status) indicates R6 to be severely cognitively impaired. R6 is indicated as being totally dependent of 2 person physical assist for bed mobility, transfer, dressing, toileting and hygiene. Section M indicates R6 is at risk for PIs and does not have any unhealed PIs. R6's Quarterly MDS, dated [DATE], indicates the following: Section M indicates R6 is at risk for PI's and has an unhealed stage 3 PI. R6's AM/PM CNA Assignment Sheet, dated 12/5/2018, indicates: Supportive devices: Wheelchair, has specialty pressure relieving mattress in place. Turning/Repositioning: ensure foam cushion is in place at all times with hole under PI to off-load and decrease pressure.Check positioning of lower leg wedge hourly to keep legs out of crisscross position. Special Care Remarks: Continue with wedge for positioning pillow placement to elevate heels to prevent skin breakdown. R6's Physician Orders, signed on 11/27/18, indicates the following: (11/30/16) Skin treatment: Check positioning of leg wedge every hour, ensure legs are not in crisscross position and that no pressure is applied to lateral sides of feet every shift. Night, AM, PM. (8/7/2018) Skin treatment: Check foam cushion with hole positioned by PI to elevate sacrum and decrease pressure to wound. Every shift N[NAME] (night) AM PM (until resolved). (9/12/18) Skin treatment: Cleanse PI to coccyx; apply skin prep to peri-wound, cover [MEDICATION NAME], Alginate, and foam then secure with [MEDICATION NAME] (tape) to secure. PM 3 times per week. Monday, Wednesday, Friday. Mattress Manufacturer form indicates: Foam Prevention Mattress, Geo-Mattress [MEDICATION NAME] is for high risk: stage 1 or single stage II pressure ulcers. 12/20/17 R6's Physician Visit Note does not indicate any skin impairments besides an ingrown toe nail. 12/30/17 R6's Skin Assessment indicated no pressure ulcers. 1/4/18 at 11:29AM Weekly Skin Assessment indicates Pressure Ulcer: Partial thickness loss of skin layers that presents as an abrasion of blister (Pressure Stage 2). Location: Coccyx, Length: 3 Width: 3. Tissue type: [MEDICATION NAME] tissue granulation tissue, with scabbed of approximately 5% (percent) (sic). Drainage: none present. No odor present . There is no evidence facility staff contacted the physician for changes in orders. 1/18/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: Unstageable; Dimensions: 3.0 x (by) 3.8 x < (less then) 0.1 cm (centimeter). Wound Base: 50% pink and 50 % slough; Exudate (a mass of cells and fluid that has seeped out of blood vessels or an organ): small serous (clear); Healing Progress: slough firmly adherent over bony prominence, no surrounding redness; Treatment: [MEDICATION NAME], foam back [MEDICATION NAME] (sterile dressing). (Please note that R6's wound has worsened from 1/4/18; it was a stage 2 and is now an unstageable. Depth is indicated at <0.1 cm when half the wound bed is covered in slough.) 1/23/18 Physician Visit Note states, in part: .Treatment. 1. Skin abrasion. Notes: this is related to almost like a cut from the string that was used to restrain the tracheal tube. We will obviously discontinue the restraining device as (R6) should have nothing placed around the neck as this would just inhibit healing.have staff just secure the [MEDICAL CONDITION] site was (sic) some paper tape at the ends for securing it and to keep the involved skin area clean with daily cleaning . Examination . able to position the neck so we could get some separation of the skin fold on the left lateral neck area where (R6) has a full-thickness disruption of the skin.perfectly straight and looks almost as if you cut it with a knife. It is right where the strain (sic) or cord from the restraining and fastening device of [MEDICAL CONDITION] present. It was completely clean .it measures 3.5 cm in length. With some manipulation I was able to inspect the entire neck area including the posterior and the right side and there is no other evidence of skin injury or irritation .(Please note there is no discussion or indication the physician looked at R6's coccyx wound in this Physician Note.) On 12/5/18 at 1:52 PM, Surveyor interviewed RN H (Registered Nurse) who was unable to find wound measurements for R6's neck ulcer and has to locate them. 1/24/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: Unstageable; Dimensions: 2.4 x 2.1 x <0.1 cm; Wound Base: 90% slough, and 10% pink; Exudate: scant and serous; Healing Progress: majority or wound bed has slough firmly adhered, some pink around inner border, irregular margins; Treatment: [MEDICATION NAME] foam back [MEDICATION NAME]. 1/26/18 at 3:47 PM Skin Problem Note states, in part: PI to coccyx has increased in size. Will monitor one more week and change treatment if there are no signs of improvement on current treatment. 2/1/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: Unstageable; Dimensions: 2.0 x 1.8 x <0.1 cm; Wound Base: 90% slough and 10% pink; Exudate: scant serous; Healing Process: small amount slough adhered with cleaning, no surrounding redness or signs/symptoms (s/s) of infection; Treatment: [MEDICATION NAME], foam boarder, [MEDICATION NAME]. 2/7/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: Unstageable; Dimensions: 2.1 x 1.9; Wound Base: 80% slough and 20% pink. Exudate: Scant serosanguineous; Healing Process: irregular margins, slough firmly adherent, no signs/symptoms of infection; Treatment: [MEDICATION NAME], foam Border [MEDICATION NAME]. 2/14/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: non-stageable; Dimensions: 2 x 1.5 x 3 mm (millimeter); Wound Base: pink and slough (no tissue percentage of wound bed indicated); Exudate: scant; Healing Process: irregular margins, slough, surrounding tissue brown; Treatment: [MEDICATION NAME]/foam. 2/15/18 Physician Note states, in part: .Examination: Examination of the left side of the neck shows the full-thickness skin ulceration area but it does appear to be approximately 30% - 40% healed compared to my last visit. It seems to be healing from the posterior aspect moving forward. The base is clean; there is no evidence of infection, no major drainage . (Please note the physician does not indicate if he was updated or include or address R6's coccyx wound in his note.) 2/24/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: nonstageable; Dimensions: 1.4 x 1.4 x 2.8 cm; Wound Base: pink and slough. (There is no indication of % of wound bed tissue); Exudate: scant; Healing Process: irregular margins, surrounding tissue pink (natural skin color); Treatment: [MEDICATION NAME]. The depth of the wound has worsened. 2/28/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: unstageable; Dimensions: 1.2 x 1.1 x 2.4 cm; Wound Base: Pink 80% and 20 % slough; Exudate: scant; Healing Process: irregular margins, slough surrounding outer edges; Treatment: Cleanse, dry, skin prep, and silicone foam. (Please note this is the first time R6's wound treatment has changed since 1/18/18. The next weekly measurement is not taken until 3/14/18.) 3/5/18 Physician Note states, in part: Reason for appointment: 1. Surg (Surgical) Consult/wound healing/ .; Treatment. 1. Decubitus ulcer; Notes: Stage 2 neck ulcer, recommend wet to dry gauze bid (twice a day), consult PT (physical therapy) for wound care at (facility name).General Examination: Neck/[MEDICAL CONDITION]: one inch neck wound, stage two ulcer . (There is no indication that the physician looked at R6's wound on coccyx, as this note does not address R6's coccyx wound.) 3/14/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: Stage 2; Dimensions: 1.5 x 1.0 x <0.1 cm; Wound Base: pink and slough; Exudate: scant; Treatment: stage 2 pink base with slough, defined edges, pink surrounding; Treatment: foam [MEDICATION NAME] with Alginate. (Please note this measurement is 14 days after the last wound assessment, there needed to be a wound assessment/measurement around 3/7/18. The PI is being documented as a stage 2 instead of an unstageable.) 3/21/18 10:09 AM General Skin Condition Note states, in part: open area r/t (related to) PI on buttock. Receiving treatment to area.Pressure ulcer on buttock - unstageable .improving .becoming smaller. 3/26/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: stage 2; Dimensions: 0.8 x 1.2 x <0.1 cm; Wound Base: pink; Exudate: scant; Healing Progress: (blank); Treatment: [MEDICATION NAME]. 3/28/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: stage 2; Dimensions: 1.2 x 1.8 x 0.1 cm; Wound Base: 50% slough and 50% pink; Exudate: Scant serous; Healing Progress: slough and ecchymotic bed, peri area is skin color; Treatment: foam [MEDICATION NAME]. 4/3/18 Physician Visit Note states, in part: Assessments 1. Skin ulcer of left side of neck, unspecified ulcer stage . Treatment: 1. Skin ulcer of left side of neck, unspecified ulcer stage. Notes: I recommended that we do more frequent dressing changes to prevent moisture to the wound by doing dry packing with gauze and change this twice daily.hopeful that over the next several months we will see gradual closure of this ulcerated area .Examination: .Examination of the ulcerated area of the left side of (resident's) neck showed that it is still full skin thickness but the base is very healthy in appearance. There is no unusual drainage or discharge. (Resident) does posture (R6's) neck with it laterally flexed so that it is difficult to get this exposed to the air and maintain dryness. There was however no surrounding [DIAGNOSES REDACTED]. Per my visual inspection, it does appear to be slightly smaller than what it had been previously. (Please note there is nothing in this Physicians Note about R6's coccyx wound.) 4/4/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: stage 2; Dimensions: 1.5 x 2.0 x 0.1 cm; Wound Base: slough 50 % and pink 50%; Exudate: Scant serosanguineous; Healing Progress: wound bed 50% slough, 50% pink tissue, defined edges, peri skin natural color, no s/s of infection; Treatment: Foam, [MEDICATION NAME] and Alginate, skin prep. (Please note R6's wound is being documented as a stage 2, when it had been documented as unstageable previously.) 4/5/18 at 12:37 PM Weekly Skin Assessment Note states, in part: .has a stage 2 to coccyx that is also receiving daily dressing changes. (Please note that R6's PI was identified as being an unstageable and is now being identified as a stage 2. Per Standards of Practice, PI's cannot be down staged.) 4/11/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: unstageable; Dimensions: 1.5 x 0.5 x 0.3 cm. Wound Base: granulation; Exudate: none; Healing Progress: granulation wound bed tendon showing, no slough, skin color peri tissue; Treatment: foam with/[MEDICATION NAME]. (Please note that tendon is visible in a full thickness loss wound, such as a stage 4 PI; this would indicate that R6's wound has worsened.) 4/19/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: unstageable; Dimensions: 1.2 x 0.5 x 0.3; Wound Base: Granulation; Exudate: none; Healing Progress: granulation wound bed, tendon showing, no slough, peri tissue pink; Treatment: Foam with Alginate [MEDICATION NAME]. 4/25/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: unstageable; Dimensions: 1.5 x 1.0 x 0.2; Wound Base: 90% slough; Exudate: small serosanguineous; Healing Progress: 90% slough, pink peri tissue, larger today; Treatment: foam, Alginate, skin barrier, [MEDICATION NAME]. (Please note that R6's wound went from granulation tissue to 90% slough in approximately a week and has increased in width by 0.5 cm.) 5/3/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: unstageable; Dimensions: 1.3 x 0.8 x 0.1 cm; Wound Base: granulation; Exudate: none; Healing Progress: granulation bed, pink peri tissue, on the healing upside now; Treatment: (blank) 5/8/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: unstageable; Dimensions: 1.8 x 0.8 x <0.1 cm; Wound Base: 50% slough, 50% granulation; Exudate: small serosanguineous; Healing Progress: bed has more slough this week, need to continue Alginate; Treatment: foam Alginate, skin barrier, [MEDICATION NAME]. 5/17/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: unstageable; Dimensions: 1.8 x 1.0 x <0.1 cm; Wound Base: 20% slough and 80% granulation; Exudate: small serosanguineous; Healing Progress: still has some slough but better, granulation tissue present, pink peri tissue; Treatment: Foam, Alginate, [MEDICATION NAME]. 5/23/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: unstageable; Dimensions: 1.0 x 0.2 x <0.1 cm; Wound Base: granulation; Exudate: scant serosanguineous; Healing Progress: granulation bed, skin colored peri tissue; Treatment: Foam, Alginate, [MEDICATION NAME]. 5/31/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: unstageable; Dimensions: 0.8 x 0.3 x <0.1 cm; Wound Base: granulation; Exudate: scant serosanguineous; Healing Progress: granulation bed, macerated peri tissue, no Alginate on when changed; Treatment: foam, Alginate, [MEDICATION NAME]. 6/5/18 Physician Visit Note states, in part: 2. Skin ulcer of neck, unspecified ulcer stage. Notes: This was cause from mechanical irritation from [MEDICAL CONDITION] neck string. This is showing healing. Will continue with daily cleansing of the wound, application of antibiotic ointment and protection with gauze.No breakdown or ulcerations of the site noted, however. The left neck wound has healed significantly but there is still a slight slit in the skin where neck skin folded, but it appeared clean without any signs of drainage . (Please note there are no measurements of R6's neck wound indicated and there is no indication if R6's coccyx wound was evaluated by the physician.) 6/6/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: Unstageable; Dimensions: 0.6 x 0.3 x <0.1 cm; Wound Base: slough 50% and granulation; Exudate: scant; Healing Progress: granulation and slough present, pink peri tissue; Treatment: foam, Alginate and [MEDICATION NAME]. (Please note that R6's wound now has 50% slough in the wound bed compared to 5/31/18 when there is no slough within the wound.) 6/14/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: Unstageable; Dimensions: 0.4 x 0.3 x <0.1 cm; Wound Base: slough 50% and granulation; Exudate: scant serosanguineous; Healing Progress: granulation tissue present to 1/2 wound, dark pink peri tissue, getting smaller; Treatment: foam, Alginate, [MEDICATION NAME]. (Please note if the wound base is 50% covered in slough, the full depth of the wound is most likely obscured, but is charted as <0.1 cm.) 6/20/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: unstageable; Dimensions: 0.5 x 0.5 x <0.1cm; Wound Base: slough 50% and granulation; Exudate: none; Healing Progress: still slough present, no dressing on, skin colored peri tissue; Treatment: foam, Alginate, and [MEDICATION NAME]. (Please note the nurse documented there was no dressing on the wound.) 6/26/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: Stage 3; Dimensions: 1.2 x 0.8 x <0.1 cm; Wound Base: granulation; Exudate: small serosanguineous; Healing Progress: bed has granulation tissue present, dark pink peri tissue; Treatment: Alginate, foam, [MEDICATION NAME]. (The wound has increased in size from the last measurement.) 7/3/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: stage 3; Dimensions: 0.8 x 0.5 x <0.1 cm; Wound Base: granulation; Exudate: scant serosanguineous; Healing Progress: granulation bed, skin colored peri tissue; Treatment: Alginate, foam, [MEDICATION NAME]. 7/11/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: Stage 3; Dimensions: 1.5 x 1.2 x <0.1 cm; Wound Base: slough and granulation; Exudate: scant serosanguineous; Healing Progress: granulation 50%, slough 50%, needs to offload, pink peri tissue. Treatment: offloading, foam [MEDICATION NAME]. (Please note that R6's mattress is not rated for being used on a stage 3 PI, and indicates R6 needs to offload.) 7/17/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: stage 3; Dimensions: 1.8 x 0.8 x <0.1 cm; Wound Base: slough and granulation; Exudate: scant & serosanguineous; Healing Progress: 80% slough, 20% granulation; Treatment: Alginate, foam, [MEDICATION NAME]. (Please note there is an increase in slough in R6's wound by 30%, after R6 was identified as needing to offload.) 7/24/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: stage 3; Dimensions: 1.8 x 1.0 x <0.1 cm; Wound Base: granulation; Exudate: scant serosanguineous; Healing Progress: granulation tissue present, pink peri tissue; Treatment: Alginate, foam, [MEDICATION NAME]. (Please note R6's wound is documented as having granulation tissue and does not mention slough tissue, yet on R6's next measurement, slough tissue is present again.) 7/31/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: Stage 3. Dimensions: 1.8 x 1.0 x <0.1 cm; Wound Base: 50% slough and 50% granulation; Exudate: scant serosanguineous; Healing Progress: bed is 50% slough, 50% granulation, pink peri tissue; Treatment: Alginate, foam, [MEDICATION NAME]. (Please note that R6's wound bed is 50% slough and is indicated as being <0.1 cm deep, when the full extent of the wound bed is unknown due to slough.) 8/7/18 Physician Visit Note states, in part: .Assessments. 1. Pressure ulcer, stage 2, coccyx. 2. Skin ulcer of left side of neck, limited to breakdown of skin . Treatment. 1. Pressure ulcer, Stage 2. Notes: Will arrange to have some form of foam cushioning (R6) (SIC) donor to elevate the sacrum out of the bed to relieve pressure to this area. They are going to continue with topical wound cares as the wound itself is clean, and I feel the critical issue is to relieve pressure to this region. They are to notify me if there is persistent lack of improvement or worsening and wound reevaluate. 2. Skin ulcer of left side of neck, limited to breakdown of skin. Notes: This once again is directly related to pressure from the [MEDICAL CONDITION] strap. I once again reinforced to staff that they were to not use a strap that would be tight or constrictive on the neck area. We had got the skin apparently to heal completely with the use of a broad band, Ace wrap, or a gauze just to avoid pressure in the neck area . History of Present Illness: .There was some concern about a possible mid buttocks ulceration or pressure area that they wish to have me check . Examination of the buttock area showed no evidence of ulceration of the buttocks, but in the mid sacral area (R6) has an approximate 2 cm very clean full-thickness pressure ulcer. This has been monitored by staff for a long time, and they feel it has been stable but is has really not been improving much, but it is definitely not getting any worse and there are no signs of infection. 8/8/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: Stage 3; Dimensions: 1.8 x 1.2 x <0.1 cm; Wound Base: granulation; Exudate: scant serosanguineous; Healing Progress: granulation bed, skin colored peri tissue; Treatment: Alginate, foam [MEDICATION NAME]. 8/14/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: stage 3; Dimensions: 1.8 x 1.1 x <0.1; Wound Base: granulation; Exudate: scant serosanguineous; Healing Progress: granulation bed, skin colored peri tissue; Treatment: Alginate, foam and [MEDICATION NAME]. 8/22/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: stage 3; Dimensions: 2.01.3 x <0.1cm; Wound Base: 20% slough and 80% granulation; Exudate: scant serosanguineous; Healing Progress: 20% slough, 80% granulation bed, lite pink peri tissue, spots with some maceration; Treatment: Alginate, foam, [MEDICATION NAME]. 8/29/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: Unstageable. Dimensions: 1.8 x 1.1 x 0.1; Wound Base: 100 % slough; Exudate: small serosanguineous; Healing Progress: complete slough, going to add [MEDICATION NAME] to treatment; Treatment: [MEDICATION NAME], Alginate and foam. (Please note that the wound bed is 100% slough, the depth of the wound will be undeterminable due to the wound bed being 100% covered with slough. In addition, the next measurement isn't until 9/12, which is two weeks from this measurement.) 9/12/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: Unstageable; Dimensions: 1.4 x 1.0 x 0.1 cm; Wound Base: 50% slough; Exudate: small serosanguineous; Healing Progress: 50% slough, 50% granulation, dark pink peri tissue; Treatment: [MEDICATION NAME], Alginate, [MEDICATION NAME]. 9/21/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: (blank); Dimensions: (blank); Wound Base: (blank); Exudate: (blank); Healing Progress: (blank); Treatment: (blank). (Please note Skin Flow Sheet is completely blank for this date, other than the date.) 9/25/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: stage 3; Dimensions: 1.3 x 1.2 x <0.1; Wound Base: 20% slough and 80% ecchymotic (subcutaneous spot of bleeding with diameter larger than 1 centimeter); Exudate: scant serosanguineous; Healing Progress: slough still present, ecchymotic bed and macerated peri tissue; Treatment: [MEDICATION NAME], foam, [MEDICATION NAME]. (Please note the last measurement for this wound was on 9/12/18.) 9/28/18 at 9:50 PM Weekly Skin Assessment Note states, in part: Skin treatment: Has pressure relieving device for bed. Receives turning/repositioning program. 10/2/18 Physician Visit Note states, in part: .History of Present Illness .The patient overall has been stable. The most difficult aspect of (R6's) cares is trying to protect (R6's) skin from breakdown. Nursing staff indicates the good news is that (R6's) neck wound apparently has completely healed. The challenging aspect is that (R6) did develop a new stage II pressure ulcer on the right heel because of contractions and mechanical irritation. Staff has appropriately been using protection with heel protection as well as use of Duoderm adhesive over the heel area. (R6) also see's podiatry regularly because of issues with regard to (R6's) toes . (Please note there is no indication in this note if the physician examined R6's coccyx wound.) 10/5/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: Stage 3; Dimensions: 1.4 x 1.2 x <0.1 cm. Wound Base: ecchymotic; Exudate: scant serosanguineous; Healing Progress: slough primarily gone, dark pink peri tissue; Treatment: [MEDICATION NAME], Alginate, foam. (No wound measurements indicated in documentation since 9/25/18.) 10/7/18 R6's Rehab to Facility Communication form indicates: Range of motion at cares, slow gradual movement to decrease hypertonic response and allow greater range. Perform to hips and knees for contracture prevention. Continue with wedge for positioning pillow placement to elevate heels to prevent skin breakdown. 10/17/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: stage 3; Dimensions: 2.0 x 1.0 x 0.2 cm; Wound Base: 20% slough, 80% dark pink; Healing Progress: still has slough, open wider this week, offloading with pillows; Treatment: [MEDICATION NAME], Alginate, foam. 10/24/18 R6's Wound Measurement Flow Sheet indicates: Wound Type: stage 3; Dimensions: 1.6 x 1.8 x <0.1; Wound Base: fuchsia; Exudate: small serous; Healing Progress: fuchsia, present, skin color peri tissue; Treatment: [MEDICATION NAME], Alginate, foam. 10/31/18 R6's Wound Measurement Flow sheet indicates: Wound Type: Stage 3; Dimensions: 1.8 x 1.3 x 0.2; Wound Base: slough; Exudate: small serosanguineous; Healing Progress: Slough covered, dark pink peri tissue; Treatment: [MEDICATION NAME], Alginate, foam. 11/7/18 R6's Wounds Measurement Flow sheet indicates: Wound Type: stage 3; Dimensions: 1.2 x 1.0 x 0.2; Wound Base: granulation 80%, slough 20%; Exudate: scant serosanguineous; Healing Progress: Granulation tissue present, dark pink peri tissue; Treatment: [MEDICATION NAME], Alginate, foam. (Please note R6 goes 15 days between wound measurements.) 11/22/18 R6's Wound Measurement Flow sheet indicates: Wound Type: Stage 3; Dimensions: 1.3 x 1.0 x 0.2 cm; Wound Base: granulation; Exudate: scant; Healing Progress: Granulation tissue present, dark pink peri tissue; Treatment: [MEDICATION NAME], foam, Alginate. 11/28/18 R6's Wound Measurement Flow sheet indicates: Wound Type: Stage 3; Dimensions: 1.8 x 0.2 x <0.1; Wound Base: Granulation; Exudate: Scant Serosanguineous; Healing Progress: Granulation tissue, skin colored peri tissue; Treatment: [MEDICATION NAME], Alginate. 12/5/18 R6's Wound Measurement Flow sheet indicates: Wound Type: Stage 3; Dimensions: 1.8 x 0.8 x 0.3; Wound Base: granulation; Exudate: Scant serosanguineous; Healing Progress: granulation tissue still present, slight maceration to peri tissue, no slough; Treatment: [MEDICATION NAME], Alginate AG, [MEDICATION NAME]. (Please note that no measurements were provided to Surveyor for R6's neck ulcer.) On 12/5/18 at 7:18 AM, Surveyor observed R6 lying in bed with head of bed up, has boots on that are plaid and pillow under upper legs, legs are crossed and touching on shins. Sides of boots on feet touching mattress, heels are not floating. No indication of a foam pad being under R6 at this time. On 12/5/18 at 10:44 AM, Surveyor observed RN H provide wound care to R6. RN H indicated to Surveyor that R6's wound measures 1.8 cm x 0.8 cm x 0.4 cm deep. RN H indicated that R6's wound is looking better and that previously it had a lot of slough, and was a stage 3. RN H indicated R6's wound is still progressing and appears to be a stage 3, with granulation tissue visible. RN H indicated boots are not pressure reducing, therapy recommended them and they're to help with friction/shear due to the way R6 moves legs. RN H indicated RN H was unsure what stage R6's [MEDICATION NAME] mattress is good for and would get back to Surveyor. RN H indicated that R6's neck wound is healed and was from trachea ties and oxygen mask sawing right into his neck, no more trachea ties to be used and indicated R6's neck wound was a stage 2, but wasn't over a bony prominence. RN H was unaware of what R6's root cause is for coccyx wound. On 12/5/18 at 1:53 PM, RN H approached Surveyor with information regarding previous interview about R6. RN H indicated that R6's Posey boots were for treatment more than prevention of PI. RN H indicated, while reviewing manufacturer recommendations, that R6's mattress is good up to a stage 2, and that R6's PI is a stage 3. RN H indicated that R6's mattress is not appropriate. RN H indicated that RD N (Regional Director), from corporate, also looks into mattresses. RN H indicated that they (higher ups and physician) meet for care conference, if there's a change in condition alert. RN H indicated that intervention selection is made between DON (Director of Nursing), physician and RN H by going through to see what is to be done. RN H was unable to find measurements for neck ulcer, currently looking for those measurement sheets. RN H indicated that R6 also had a stage II on heel, which is now healed. On 12/5/18 at 3:54 PM, Surveyor observed R6 lying in bed, legs crossed, sheep skin between shins, no cushion between legs, pillow under thighs, side of feet resting on mattress in boots. Does not appear to have a cushion under R6's bottom. On 12/5/18 at 4:17 PM, Surveyor observed R6, with RN I, lying on back, with legs crossed. RN I indicated to Surveyor that R6 only has a draw sheet and soaker pad under R6. Surveyor asked RN I about a foam cushion with a cut out; RN I indicated RN I will have to ask the CNAs where it is. Surveyor asked RN I about R6's care plan indicating to have a cushion between legs. RN I stated, that is a good question, it really doesn't work very well, RN I indicated that usually the CNAs position the cushion, and RN I is not sure if it's supposed to be between R6's legs. On 12/6/18

Based on observation, interview, and record review, the facility did not ensure that a resident having pressure ulcers received the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 2 of 4 residents (R) reviewed for treatment and prevention of pressure ulcers (R1 and R6). R1 was admitted to the facility without a pressure injury (PI) and was identified to be at risk for development. The facility identified that R1 has two PIs on 10/26/17. R1 remained in the facility until 11/16/17; when he was sent to the hospital and did not return to this facility. The facility noted the following PIs: 1. Right lower buttock - Stage 2, and Posterior Helix (Back of the ear) - Stage 2. The facility did not do the following: 1. Measure the width of the PI to R1's right (R) lower buttock when it was initially identified 2. Did not measure the PI to R1's R ear 3. Did not measure either of these PIs after they were identified on 10/26/17 (three weeks). 4. When R1 went to the hospital on [DATE], the hospital identified that R1 had an unstageable PI to his R heel, an unstageable PI on his left (L) ankle, and a Stage 2 PI to his R knee. The facility was unaware of these PIs and has no documentation or orders for these PIs. 5. After the facility discovered the two PIs on 10/26/17, they did not put additional interventions in place to off-load pressure and to prevent additional PIs from developing. R6 developed a Stage 2 PI to her L ischium (buttock). On 12/11/17, the staff left R6 sitting in her wheelchair from breakfast through lunch without repositioning or off-loading R6 from this pressure point. This is evidenced by: The facility policy entitled Skin Care Management, dated 6/17, states, as follows: It is the policy of this nursing home to provide skin care to residents that includes assessment, prevention of skin breakdown and management of pressure injury and other skin integrity concerns. 5. Skin is monitored routinely during care giving, and problems identified will be documented on the Skin and Body Assessment Form. Skin integrity will be monitored at least weekly on the resident's bath day for all residents that are identified at risk. For residents with medical devices, skin will be inspected on every shift under and around devices for signs a symptoms of pressure-related injury to surrounding tissue. 6. c. Measurement of the area will be done using a wound measuring guide. 6. d. A weekly assessment and associated documentation will be done by the nurse using the Skin Care Flow Sheet (or electronic equivalent). If paper-based, this will be filed in the Assessment section of the resident's record upon completion. Staging of Pressure Ulcers: The facility follows the National pressure Ulcer Advisory Panel (NPUAP) guidelines for Prevention and treatment of [REDACTED]. Pressure ulcers are staged using the system below: Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present, but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. *Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined . Example 1 R1 was admitted to the facility on [DATE] with Diagnoses: [REDACTED]. R1 sustained the traumatic fractures when he jumped out of a second story window at an Assisted Living/Memory Unit where he was residing at the time. R1 has a court-appointed Guardian. R1's admission Braden assessment, dated 9/1/17, indicates R1 scored 17 indicating R1 was at risk for PI development. The facility's Braden risk score indications are as follows: At Risk: 15-18, Moderate Risk: 13-14, High Risk: 10-12, Very High Risk: 9 or below. R1's admission MDS, dated [DATE], indicates a Brief Interview for Mental Status (BIMS) was completed, with R1 scoring a 13, indicating he is cognitively intact. Section M0150 of the MDS indicates R1 is at risk for developing pressure ulcers. Section G0110, ADLs indicates R1 requires 2 staff and extensive assist for bed mobility and transfers. The Care Area Assessment (CAA) worksheet states, No pressure ulcers, requires staff assistance to move sufficiently to relieve pressure over any one site. [MEDICATION NAME] Risk: Incontinence, Immobility. medications: [REDACTED]. Treatments: Newly admitted , bedfast or wheelchair bound, functional limitation in range of motion, devices that can cause pressure (oxygen, indwelling catheter tubing, TED hose, casts, splints). Description of problem: At risk for skin breakdown. Care Plan: Will develop care plan. R1's Comprehensive Care Plan for Potential for Tissue Integrity Impairment related to lack of appetite, multiple medical conditions, and recent immobility. Goal: Free of irritation, 12/20/17 - three months. Nurses: Assess skin status, assess nutrition status, keep MD (Medical Doctor) informed, administer [MEDICATION NAME] as ordered, refer to dietician. Nurse Aide: Keep skin clean and dry, encourage and assist to reposition, inspect skin daily, report changes. R1's CNA Assignment Sheet states as follows: Transfer: Assist of 1 - encourage non-weight bearing to L foot. He will choose to use it at times. Toileting: Uses bedside commode. Turning/Repositioning: Assist of 1. (Note, frequency is not indicated). Skin Care: offer to lotion extremities with cares It is important to note that R1's Comprehensive Care Plan for Potential for Tissue Integrity Impairment does not indicate any skin impairment, nor was the Comprehensive Care Plan revised after the facility noted two PIs on 10/26/17. On 10/19/17 at 1:30 PM, the Physician Assistant (PA) wrote an order stating NWB LLE (Non-weight bearing left lower extremity). Boot to LLE. May remove to shower and begin working on ankle ROM (Range of Motion). Elevate as needed for [MEDICAL CONDITION] control. Check skin of LLE 3-4 times per day to ensure no pressure sores (PI) developing. F/U (follow up) in 3-4 weeks. (It is important to note that the facility has no documentation that R1's skin was being assessed 3-4 times per day. A PI measuring 19x20 mm was noted by the hospital on [DATE] (see note below.)) The only documentation the facility has for R1's PIs is as follows: 10/26/17 Weekly Skin Assessment - Has abrasion/bruise present in past 7 days. Pressure Ulcer: Partial thickness loss of skin layers that presents as an abrasion or blister (Pressure Stg (Stage) 2). Location: R lower buttock. Length: 4 cm (centimeter). Width Not measurable. Wound Tissue: Reddened. Drainage: None present, no odor present, small areas of superficial skin removed. Surrounding Tissue: Normal for client. Healing Progress: No change. Teaching Done: Skin care precautions: Non-adhesive foam in place, client encouraged to change position in recliner, call light given, assistance from staff encouraged. Receives turning and repositioning program. Legs elevated, repositioning area cleaned with normal saline, non-adhesive foam dressing applied. The facility did not revise the care plan subsequent to the development of these PIs and did not monitor or assess these areas over the next three weeks. On 11/16/17, R1 saw the Nurse Practitioner (NP) at the Orthopedic Surgery Clinic. The NP noted the following under Physical Exam: His (R1) L ankle does demonstrate a pressure sore over the medial aspect that appears partial-thickness. There is a little bit of black eschar in the central area surrounded by a red area. It measures 19 x 20 mm (millimeters). There is no drainage. It does not appear infected. The lateral incision (surgical) is well-healed. (It is important to note that the facility has no documentation of this necrotic PI.) Assessment/Plan: R1 is a [AGE] year old man who is 9 weeks status [REDACTED]. R1's ankle radiographs appear stable and he does have a pressure ulcer over the medical aspect that I do not think appears infected at this time. Would recommend a [MEDICATION NAME] dressing, discontinuing his boot to offload any pressure from this area. History of Present Illness: He was in Orthopedics today to see the MD and get is surgical L ankle checked and was referred to emergency room (ER) immediately. He has multiple necrotic pressure wounds. The body diagram from the hospital indicates the following PIs: Right heel - Necrotic ulcer (Unstageable) Right knee - blister, fluid filled (Stage 2) 11/16/17 - R1 was sent from the clinic to the hospital ER. The NP in the ER notes the following: Soon after calling the SNF (skilled nursing facility in which R1 resides) the Administrator, NHA A (Nursing Home Administrator), called the Emergency Department to inquire why records were being requested. The ER Nurse asked the NP to talk to NHA A. NHA A wanted to know why records were being requested. The NP told NHA A records were needed for continuation of care. R1 is showing signs [MEDICAL CONDITION] (from a scrotal abscess) and hospital needs all the information possible to determine history of illness. NHA A reported that R1 saw his PCP (Primary Care Physician) yesterday and there were no concerns about R1's health. The NP told NHA A that there are concerns about patient's inability to straighten out his legs and various pressure ulcers in various stages that were not dressed On 12/11/17 at approximately 5:00 PM, Surveyor spoke with DON B. Surveyor asked DON B how frequently she would expect staff to measure PIs. DON B stated PIs should be measured weekly. Surveyor asked DON B, when a PI is measured should staff note the length, width, and depth (if applicable). DON B replied, Yes. Surveyor asked DON B if she was aware of the PIs the hospital documented during R1's visit on 11/16/17. DON B stated, No. DON B stated when the facility identifies wounds/PIs, they do weekly wound rounding. DON B stated that R1's PIs should have been measured weekly. DON B does not know why the PIs were not measured for 3 weeks prior to admission to the hospital. DON B stated CNAs are to inspect skin daily. (It is important to note that the facility has no documentation that this was being done.) DON B and Surveyor reviewed R1's Comprehensive Care Plan. DON B stated there are no interventions on R1's Comprehensive Care Plan to protect his heels and that the care plan indicates that R1 is to be turned and repositioned, but does not indicate how often is to be repositioned. DON B stated floating heels should be on R1's care plan. DON B agreed that the P1s identified at the hospital should have been identified in house. The facility has no evidence that R1's care plan was revised to prevent further skin breakdown after they noted that R1 had developed two PIs on 10/26/17. Example 2 R6 was admitted to the facility on [DATE]. R6's [DIAGNOSES REDACTED]. R6's Significant Change MDS assessment, dated 11/24/17, indicates that R6 has severe cognitive impairment. Section G of the MDS notes that R6 is totally dependent on staff for repositioning, transferring (from chair to bed) and toileting. Section M notes, in part, that R6 was at risk for pressure ulcers and had 1 unstageable pressure ulcer. R6's Braden Score (Pressure Injury Risk Assessment) on 12/2/17, was 13, indicating high risk. R6's Comprehensive Care Plan, dated 12/1/17, includes, in part: Problem: Tissue integrity impairment related to incontinence, decreased cognition, weight loss, and change in mobility .Interventions: Monitor skin status every shift and notify MD of changes .air overly on bed . Encourage and assist to reposition .Attempt to get up for meals and lay down in afternoon for rest as she is willing . encourage intake of food and fluids .Toilet every two hours and as needed. Reposition every two hours and with incontinent care. R6's Treatment Orders on 11/17/17: cleanse L lower buttock with wound cleanser, apply thin [MEDICATION NAME] dressing, 3 times per week. R6's Skin Care Flow Sheet, dated 11/17/17, notes a Stage 2 PI on her L lower buttock, measuring 0.8 cm x 0.5 cm x 0.1 cm. R6's wound was assessed weekly and measurements on 12/8/17 were documented as measuring 3 cm by 1 cm. On 12/11/17 at 9:15 AM, 10:30 AM and 11:45 AM, Surveyor observed R6 sitting up in wheelchair in dining area. On 12/11/17 at 1:15 PM, Surveyor observed CNA D and CNA E transfer R6 from her wheelchair to her bed with a total lift machine. R6 was wearing an incontinent brief, which was wet. CNA's provided peri care and noted that the dressing on R6's L ischium was loose. CNA E stated that she would get the nurse. At 1:20 PM, LPN C (Licensed Practical Nurse) came in to change R6's dressing. Surveyor observed an open area about 3 cm by 1 cm with a red wound base to R6's L ischium. LPN C stated that she had a call into the doctor to request a change in the treatment, as R6's wound had become more macerated with the use of the [MEDICATION NAME] dressing. On 12/11/17 at 1:30 PM, Surveyor interviewed CNA D about the cares she had provided to R6 that day. CNA D stated that she had gotten R6 up by 8:00 AM for breakfast. Surveyor asked CNA D how often R6 should be repositioned. CNA D stated every two hours. Surveyor asked CNA D if she had repositioned, weight shifted or off-loaded R6 from sitting in her wheelchair since 8:00 AM. CNA D stated that she had not; CNA D stated that she could have laid R6 down or asked her if she wanted to lie down. On 12/11/17 at 1:35 PM, Surveyor interviewed LPN C about R6 not being repositioned. LPN C stated that it was hard to get to everything with all the needs of the resident on the unit. On 12/11/17 at 2:00 PM, Surveyor interviewed DON B about R6 and how often she expected staff to reposition R6. DON B stated at least every two hours. R6 had a Stage 2 PI to her L ischium and the facility did not ensure protective measures were in place to promote healing of this wound.

Based on observation, record review and interview, the facility did not ensure that all residents with dementia receive appropriate assessments, cares and interactions to maintain the highest practical quality of life for all the residents on the dementia unit (25 residents). The first two examples are determined to be a G level and the additional observations are at a lower severity. 1. Resident #1 was admitted to the facility ambulating independently and was on an antidepressant. Resident #1 had a continual increase in antidepressant and additions of antianxiety and antipsychotic meds. Resident #1 experienced increased behaviors, increased pain and lack of meaningful activities and interactions. 2. Resident #11 was observed wandering both on the unit and exiting the unit. Facility staff continually told Resident #11 to sit down in a chair. No meaningful interaction or activities were offered to occupy Resident #11. 3. During general observations of the dementia unit, residents were not engaged in meaningful activities or interaction to maintain a quality of life. As evidenced by: Resident #1 was admitted on [DATE]. Resident #1 has a [DIAGNOSES REDACTED]. Upon admission, Resident #1 ambulated independently, was on an antidepressant and was at risk for pain. The comprehensive care plan states resident is at risk for alteration in thought process due to advancing Alzheimer's/dementia, depression and anxiety, which is manifested by paranoia, suspicious thoughts, yelling, crying and persistent sadness. The care plan states staff are to offer non-pharmacological interventions such as back rubs, warm milk, and snacks. Staff are to engage resident in activities as much as possible. She enjoys walks, playing cards, watching television and sweets, specifically rice krispie treats and root beer. Resident also responds well to heat, ice and massage when in pain. On 08/26/14, Surveyor observed the following for Resident #1: - 7:30 a.m.: Resident in wheelchair in activity area at the table. Surveyor did not observe any social interaction between staff and the resident. No activities were provided to Resident #1 at this time. No snacks or fluids were offered. Resident #1 was not offered to watch television or to play cards. No pillow was being used, while in the wheelchair, for comfort and to maintain proper body alignment. - 8:15 a.m.: Resident in wheelchair in dining room. Surveyor did not observe any social interaction between staff and the resident. No activities were provided to Resident #1 at this time. No snacks or fluids were offered. Resident #1 was not offered to watch television or to play cards. No pillow was being used, while in the wheelchair, for comfort and to maintain proper body alignment. - 8:30 a.m.: Resident in wheelchair in dining room. Surveyor did not observe any social interaction between staff and the resident. No activities were provided to Resident #1 at this time. Resident #1 was not offered to watch television or to play cards. No pillow was being used, while in the wheelchair, for comfort and to maintain proper body alignment. - 9:00 a.m.: Resident in wheelchair in dining room crying. Surveyor did not observe any social interaction between staff and the resident. No activities were provided to Resident #1 at this time. Facility staff did not offer touch therapy, heat, ice, massage, back rubs, warm milk or 1:1 interactions. No activities were provided to Resident #1 at this time. Resident #1 was not offered to watch television or to play cards. No pillow was being used, while in the wheelchair, for comfort and to maintain proper body alignment. - 9:25 a.m.: Resident in wheelchair in dining room. Surveyor did not observe any social interaction between staff and the resident. No activities were provided to Resident #1 at this time. No pillow was being used, while in the wheelchair, for comfort and to maintain proper body alignment. - 9:40 a.m.: Resident in wheelchair in dining room crying. Facility staff did not offer touch therapy, heat, ice, massage, back rubs, warm milk, snacks or 1:1 interactions. No activities were provided to Resident #1 at this time. Resident #1 was not offered to watch television or to play cards. No pillow was being used, while in the wheelchair, for comfort and to maintain proper body alignment. - 9:45 a.m.: Resident in wheelchair in dining room crying. Facility staff removed Resident #1 from the dining room and placed her in the activity area. Facility staff did not offer touch therapy, heat, ice, massage, back rubs, warm milk, snacks or 1:1 interactions. No activities were provided to Resident #1 at this time. Resident #1 was not offered to watch television or to play cards. No pillow was being used, while in the wheelchair, for comfort and to maintain proper body alignment. - 9:50 a.m.: Resident in wheelchair in activity area crying. Facility staff did not offer touch therapy, heat, ice, massage, back rubs, warm milk, snacks or 1:1 interactions. No activities were provided to Resident #1 at this time. Resident #1 was not offered to watch television or to play cards. No pillow was being used, while in the wheelchair, for comfort and to maintain proper body alignment. - 9:55 a.m.: Resident in wheelchair in activity area crying. Facility staff did not offer touch therapy, heat, ice, massage, back rubs, warm milk, snacks or 1:1 interactions. No activities were provided to Resident #1 at this time. Resident #1 was not offered to watch television or to play cards. No pillow was being used, while in the wheelchair, for comfort and to maintain proper body alignment. - 10:10 a.m.: Resident in wheelchair in activity area crying. Facility staff did not offer touch therapy, heat, ice, massage, back rubs, warm milk, snacks or 1:1 interactions. No activities were provided to Resident #1 at this time. Resident #1 was not offered to watch television or to play cards. No pillow was being used, while in the wheelchair, for comfort and to maintain proper body alignment. - 10:12 a.m.: Resident in wheelchair in activity area crying and yelling out loudly. Activity Aide (AA) Z removed Resident #1 from the activity area and placed her near the central area of the unit. Facility staff did not offer touch therapy, heat, ice, massage, back rubs, warm milk, snacks or 1:1 interactions. No activities were provided to Resident #1 at this time. Resident #1 was not offered to watch television or to play cards. No pillow was being used, while in the wheelchair, for comfort and to maintain proper body alignment. - 10:20 a.m.: Resident in wheelchair in central area crying softly. Facility staff did not offer touch therapy, heat, ice, massage, back rubs, warm milk, snacks or 1:1 interactions. No activities were provided to Resident #1 at this time. Resident #1 was not offered to watch television or to play cards. No pillow was being used, while in the wheelchair, for comfort and to maintain proper body alignment. - 10:33 a.m.: Resident in wheelchair in central area. Facility nurse offered Resident #1 a sip of juice and then walked away. Facility staff did not offer touch therapy, heat, ice, massage, back rubs, warm milk, snacks or 1:1 interactions. No activities were provided to Resident #1 at this time. Resident #1 was not offered to watch television or to play cards. No pillow was being used, while in the wheelchair, for comfort and to maintain proper body alignment. - 10:40 a.m.: Resident in wheelchair in central area crying and yelling out. Facility staff did not offer touch therapy, heat, ice, massage, back rubs, warm milk, snacks or 1:1 interactions. No activities were provided to Resident #1 at this time. Resident #1 was not offered to watch television or to play cards. No pillow was being used, while in the wheelchair, for comfort and to maintain proper body alignment. - 11:00 a.m.: Resident in wheelchair in dining room with Occupational Therapist. Resident #1 appeared to be more calm during therapy session. No pillow was being used, while in the wheelchair, for comfort and to maintain proper body alignment. - 11:15 a.m.: Resident in wheelchair in dining room with Occupational Therapist. Resident #1 appeared to be more calm during therapy session. No pillow was being used, while in the wheelchair, for comfort and to maintain proper body alignment. - 11:45 a.m.: Resident in wheelchair in dining room with Occupational Therapist. Resident #1 appeared to be more calm during therapy session. No pillow was being used, while in the wheelchair, for comfort and to maintain proper body alignment. - 12:00 p.m.: Resident in wheelchair in dining room. No pillow was being used, while in the wheelchair, for comfort and to maintain proper body alignment. Surveyor did not observe Resident #1 being ambulated by staff according to plan of care. Surveyor did not observe staff checking Resident #1's comfort level every two hours according to her plan of care. No rice krispie treats, sweets or root beer were offered to Resident #1 during this time. Surveyor did not observe nursing staff assess Resident #1 during the above mentioned times for pain, discomfort or behaviors. Surveyor did not observe facility staff offer toileting to Resident #1 during the above mentioned times. Surveyor did not observe facility staff offer frequent rest periods to Resident #1. On 08/27/14 at 2:30 p.m., Surveyor observed Certified Nursing Assistant (CNA) T and CNA U attempting to ambulate Resident #1 in the activity area. Resident #1 was crying and yelling out. CNA T was attempting to place the gait belt on Resident #1 and resident was yelling, "Ouch...ouch" very loudly. The Assistant Director of Nursing (ADON) K walked by Resident #1 and stated, "Oh (Resident #1), (Resident #1)" and then walked away. Resident #1 continued to yell and cry out while both CNA T and CNA U were putting on the gait belt. CNA U placed a walker in front of Resident #1 to assist with ambulation. Resident #1 screamed loudly, "No." CNA T took Resident #1's hands and placed them on the bar of the walker and Resident #1 continued to scream, "No." Both CNA T and CNA U attempted to raise Resident #1 into a standing position with the use of the gait belt and Resident #1 started screaming, "It hurts...it hurts...stop." CNA T and CNA U did not stop attempting to ambulate Resident #1. Resident #1 was very agitated and attempted to swat at CNA T with her hands. Resident #1 ended up sitting back down in her wheelchair crying and screaming, "Stop...it hurts." Resident #1 was pounding her walker on the floor. CNA T and CNA U again attempted to ambulate Resident #1 and she continued crying and yelling out, "It hurts...it hurts." The Assistant Director of Nursing (ADON) stood off to the side and did not offer assistance and did not request CNA T and CNA U to stop attempting to ambulate the resident. Licensed Practical Nurse (LPN) J came over to Resident #1 and wheeled her over to a chair located next to the wall. LPN J and CNA U then picked her up out of the wheelchair and placed her in the chair next to the wall. Resident #1 cried and screamed loudly during the process of being picked up stating, "Stop....no...it hurts." After being placed in the chair, LPN J removed the gait belt, placed a walker in front of the resident and walked away. Resident #1 softly cried and started to calm down. On 08/27/14 at 3:00 p.m., Surveyor observed Resident #1 sitting in her wheelchair in the East day room crying. CNA U approached Resident #1 and asked, "What's the matter?" Resident #1 did not answer and continued to cry. CNA U walked away. The resident continued to cry. At 3:07 p.m., CNA T approached the resident and stated "Hi (Resident #1), how are you?" Resident #1 continued to cry. CNA T offered Resident #1 a cup of hot cocoa. The resident continued to cry, and stated, "If it doesn't kill me." CNA T walked away. Resident #1, crying, stated, "Where did he go? Never, Never..." At 3:15 p.m., CNA T told LPN J that he had made Resident #1 a cup of hot cocoa. LPN J took the cup of hot cocoa from CNA T and assisted Resident #1, who was still crying, to a long table. LPN J stated, "I'll help you," and proceeded to assist Resident #1 with drinking the cocoa. After the task was completed, LPN J left the table. The resident was left sitting alone at the table; however, she had stopped crying. On 08/27/14 at 2:40 p.m., Surveyor interviewed ADON K, discussing concerns of staff not stopping ambulation with Resident #1 when she was yelling out and telling them to stop and staff picking her up, transferring her to a chair when the resident was crying and yelling out to stop and that it hurt. ADON K stated Resident #1 has severe pain and was not sure what the staff could do. ADON K stated staff should have stopped attempting to transfer Resident #1 and go get the floor nurse to assess. Surveyor asked ADON K if Resident #1's pain was being appropriately addressed and ADON K stated she did not know. On 08/27/14 at 3:00 p.m., Surveyor interviewed CNA U. Surveyor discussed concerns in regard to transferring Resident #1 while she was crying, screaming to stop and stating it hurt. CNA U stated she was told by LPN J that Resident #1 needed to be ambulated and was told they (CNA U and CNA T) did not have a choice. CNA U stated when they first approached Resident #1 to ambulate it was obvious Resident #1 was agitated. CNA U stated she suggested to LPN J not to ambulate her and to just leave her alone. CNA U stated that LPN J told her Resident #1 needed to be ambulated regardless. CNA U stated she had worked on the unit for a long time and knows the resident very well. CNA U stated she knows that if Resident #1 is agitated or upset that you need to re-approach her because if you don't, her behaviors will escalate. Surveyor asked CNA U if she felt Resident #1 was in pain and CNA U stated, "Yes...she has a lot of pain all the time." On 08/27/14, Surveyor interviewed CNA T, discussing the observation of transferring Resident #1 while she was crying, screaming to stop and stating it hurt. CNA T stated LPN J had told them to ambulate Resident #1. Surveyor asked CNA T if he should have stopped transferring the resident when she started screaming and crying and telling them it hurt and to stop. CNA T stated he did not hear the resident screaming and telling them to stop and that it hurt. On 08/27/14 at 3:06 p.m., Surveyor interviewed LPN J. Surveyor discussed the observation of Resident #1 being transferred while crying, screaming to stop and stating it hurt, and CNA T and CNA U stating they were told to ambulate Resident #1 regardless of the agitation, crying and pain. LPN J stated she did ask CNA T and CNA U to ambulate the resident and to toilet her. LPN J stated she did not "order" the staff to do it. Surveyor asked why no pain assessment or non-pharmacological interventions were being used to assist Resident #1. LPN J stated it was very hard to keep an eye on her because the dementia unit is so busy. LPN J stated there are too many residents on the unit that have behaviors and the staff are trying to do the best they can do. LPN J stated the resident is usually in another room and is not always visible to her. Surveyor asked LPN J if she felt Resident #1's pain was being controlled and LPN J stated, "Sometimes...just doing the best we can do." On 08/28/14, Surveyor interviewed the Director of Nursing (DON), discussing the observation of Resident #1 being transferred while crying, screaming, stating it hurt and to stop. Surveyor discussed concerns in regard to Resident #1 being able to ambulate independently, then receiving multiple increases in [MEDICATION NAME] and now is no longer able to ambulate on her own. The DON stated she felt Resident #1's ambulation status was due to her dementia and not the increase in medications. Surveyor asked the DON if the interdisciplinary team (IDT) had discussed the ambulation status of Resident #1 and the DON stated, "I don't really know." Surveyor discussed concerns in regard to no activities being offered to Resident #1 during the day along with no non-pharmacological interventions. The DON stated she would have to look into the situation and get back to Surveyor . No further infornmation was provided. On 08/28/14, Surveyor requested all copies of IDT notes addressing Resident #1's pain that would identify root cause and analysis. No IDT notes provided to Surveyor . Surveyor requested all copies of IDT notes in regard to Resident #1's ambulation status that would identify the root cause and analysis or the decline in ambulation. No IDT notes provided to Surveyor . On 08/27/14 at 2:00 p.m., Surveyor requested medication changes for all antipsychotics, antidepressants and antianxiety given to Resident #1 from date of admission from the DON. Upon receipt of all medication changes given, Surveyor noted the following: - 05/30/14: Resident #1 was admitted to facility on 10/13/14 with an order for [REDACTED]. - 05/30/14: Resident #1 received new physician order [REDACTED]. - 06/03/14: Resident received a new order for [MEDICATION NAME]/[MEDICATION NAME], one tablet, 5mg/325mg every four hours as needed for pain. - 06/16/14: Resident #1 had a change in [MEDICATION NAME] order. New order received was to increase [MEDICATION NAME] to 25 mg three times a day for a total of 75 mg daily due to increase in behaviors. - 06/18/14: Resident #1 received a new order for an [MEDICATION NAME] Patch 13.3mg to be given every 24 hours to assist with management of Alzheimer dementia. - 07/30/14: Resident #1 had a change in [MEDICATION NAME] order. New order received was to increase [MEDICATION NAME] to 50 mg twice a day and an additional 25 mg at night for a total of 125 mg daily due to increase in behaviors. - 07/30/14: Resident #1 received a new order for [MEDICATION NAME] 25 mg twice a day for pain and to decrease signs and symptoms of behaviors. - 08/06/14: Resident #1 received a new order for scheduled [MEDICATION NAME]/[MEDICATION NAME] 5mg/325mg, one tablet twice a day and as-needed for pain. On 08/27/2104, Surveyor reviewed side effects for above noted medications and noted the following: - [MEDICATION NAME]: malaise, [MEDICAL CONDITION], dizziness, drowsiness, tremors, agitation, fatigue, pain, visual disturbances, abdominal pain, behavioral changes and suicidal ideation's. - [MEDICATION NAME]: Dizziness, headache, weakness, sedation, orthostatic [MEDICAL CONDITION], abdominal pain, death, back pain, and [MEDICAL CONDITION]. - [MEDICATION NAME] Patch: Stomach pain, headache, tired feeling, anxiety, depressed mood, dizziness and sleeping problems. - [MEDICATION NAME]/[MEDICATION NAME]: Anxiety, dizziness, drowsiness, upset stomach, headache, mood changes and blurred vision. - [MEDICATION NAME]: Dizziness, headaches and abdominal pain. Surveyor was unable to locate any nursing assessments or IDT notes in regard to pain, decline in ambulation, headaches or agitation possibly being caused from above mentioned medications. On 08/26/2014 at 7:25 a.m., Surveyor observed CNA L and CNA O perform daily cares for Resident #1. Both CNA L and CNA O assisted in transferring Resident #1 into the bathroom by use of an EZ stand and then into her wheelchair. This surveyor asked CNA L and CNA O if Resident #1 could ambulate on her own and both CNA L and CNA O stated, "no." CNA O stated Resident #1 was independent a "few months ago" but no longer was able to do so. CNA L stated Resident #1 stated Resident #1 has had an increase in agitation and paranoia sometimes requires the use of the EZ stand to help her transfer. Both CNA O and CNA L stated Resident #1 was at high risk for falls and has had many falls in the past couple of month. Both CNA O and CNA L stated Resident #1 had a very unsteady gait. On 08/27/14 at 2:00 p.m., Surveyor interviewed the DON. Surveyor asked the DON what the ambulation status of Resident #1 was when she was admitted to the facility on [DATE]. The DON stated Resident #1 was ambulating independently. The DON stated Resident #1 was independent in ambulation up until around June 2014. The DON stated Resident #1 can no longer ambulate on her own. Surveyor asked the DON if perhaps all the increases in Resident #1's antipsychotic medication, [MEDICATION NAME], could have an effect on Resident #1 currently not being able to ambulate. The DON stated, "It may seem like a lot to someone who is healthy but we don't feel the increases in medication are the cause of why Resident #1 is no longer ambulating...we believe it is due to her disease progression, falls, and [MEDICAL CONDITION]." On 08/26/14, Surveyor reviewed all falls for Resident #1 from 05/01/14 - 08/25/14. Resident #11 had multiple falls during this time frame, which some resulted in injury. Surveyor was unable to locate assessments, completed by the facility, that would have identified side effects of above mentioned medications. 2. On 08/27/14, Surveyor reviewed the medical record for Resident #11 and noted the following: - Resident #11 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. - MDS, dated [DATE], indicated Resident #11 was severely cognitively impaired and had hallucinations. MDS did not indicate Resident #11 wandered. - Comprehensive Nursing care plan, received 08/27/14, titled, "Self Care Deficit," stated for staff to provide 1:1 visits and to base length of visits on attention span and level of comfort. Care plan states brown construction paper was put on the glass windows of the doors exiting the dementia unit to deter the resident from exiting the unit. - Comprehensive Nursing care plan, received 08/27/14, titled, "Alteration in Thought Processes," states social services is to encourage one on one conversations and to encourage participation in activities. The care plan states the activity department is to assist to all activities. Care plan states resident enjoys watching people and watching television. Care plan states resident does wander and will attempt to leave the unit. - CNA care plan, received 08/27/14, states Resident #11 has a developmental cognition with periods of hallucinating, wanders and is non-verbal. Care plan states offer toileting when wandering as he appears to do less wandering, offer and assist to toilet every two to three hours and as needed. On 08/26/14, Surveyor observed the following for Resident #11: - 10:20 a.m.: Resident #11 was standing in the central unit staring at the exit door which contained brown construction paper which blocked view into the hallway. Resident #11 then wandered into the nursing charting room where he stood all alone. A facility staff member entered the room and assisted Resident #11 out of the charting room and requested that he sit down in a chair. Resident #11 sat down in the chair and the facility staff member walked away. - 10:22 a.m.: Resident #11 stood up from the chair and walked into the day room. He then left the day room and stood in the central unit staring at the exit door. Resident #11 then approached the exit door and left the unit. Facility staff on the unit ran out into the hallway and led Resident #11 back into the unit. Facility staff member led Resident #11 to a chair and requested that he sit down. Resident #11 sat down and the facility staff member walked away. - 11:05 a.m.: Resident #11 walked into the medication room where LPN BB was standing in front of the medication cart. LPN BB led Resident #11 out of the medication room and requested he sit down in a chair in the hallway. Resident #11 sat down. - 11:08 a.m.: Resident #11 stood up and CNA O walked by and told the resident to sit back down in the chair. Resident #11 sat back down and CNA O walked away. - 11:15 a.m.: Resident #11 stood up from the chair, walked to the exit doors and left the unit. CNA Y left the unit and led Resident #11 back into the unit. CNA Y brought Resident #11 back to the chair in the hallway and requested him to sit down. Resident #11 sat down. - 11:25 a.m.: Resident #11 stood up and attempted to exit the dementia unit. CNA Y again led Resident #11 back to the unit and requested he sit down in the chair. Resident #11 sat down in the chair. - 11:27 a.m.: Resident #11 stood up and walked toward the exit door. CNA Y led Resident #11 into the day room, which had glass doors, and closed the doors. Resident #11 was in the day room with the glass doors shut standing in the center of the room staring out into the central unit. A family member, who was visiting a resident at the time, was watching Resident #11 attempting to open the door but was unsuccessful. The family member told LPN BB that she did not know what to do and should she let him (Resident #11) out of the day room. LPN BB told the family member she was busy and would have to take care of him (Resident #11) later and there wasn't enough staff to take care of him right now. The family member looked concerned but did not attempt to open the door to the day room to let Resident #11 out. Resident #11 eventually opened the door to the day room, exited the day room and attempted to exit the dementia unit. Facility staff on the dementia unit left the unit and led Resident #11 back into the unit and requested he sit down in a chair in central unit. Resident #11 sat down in the chair. - 11:45 a.m.: Resident #11 walked to the exit door and left the dementia unit. Facility staff on the unit led Resident #11 back into the unit and requested he sit down in a chair in the central unit. Staff offered no activities to Resident #11 while on the unit. No 1:1 interactions with staff were observed by this surveyor while on the unit during survey. Resident #11 was observed exiting the unit multiple times throughout survey and was requested to sit in a chair each time. Surveyor observed shelves in the activity area that contained supplies for crafts, music and miscellaneous items for activities. None of these items were used to provide Resident #11 an activitiy during observations. On 08/27/14, Surveyor interviewed LPN BB and discussed concerns in regard to Resident #11 attempting to elope multiple times throughout the day and then being requested to sit in a chair and no activities or social interaction provided. LPN BB stated it was almost impossible for the staff to do this because there were too many residents with behaviors on the unit and not enough staff to meet their needs. LPN BB stated it was difficult for her to do her job because she was constantly running after Resident #11 due to attempting to elope from the dementia unit. LPN BB stated the dementia unit needed more staff to meet the needs of the residents on the unit. 3. On 08/26/14 at 7:30 a.m., Surveyor observed five residents sitting at a long table in the activity area of the dementia unit. No music or activities or social interactions was being provided. Facility staff members came and got the five residents at approximately 8:15 a.m., moving them to the dining room for breakfast. On 08/26/14 at 2:00 p.m., Surveyor observed seven residents sitting at a long table in the activity area of the dementia unit. One residents was chewing on a plastic plant. No facility staff noted to be socially interacting with residents. One facility staff member walked over to the table, removed the plastic plant from the resident's mouth, placed it on the table and then walked away. No activities were provided to these seven residents and they sat in their wheelchairs at the table. On 08/27/14 at 11:15 a.m., Surveyor observed a resident in her wheelchair, hunched forward, and had gotten her wheelchair stuck on a chair in the hallway. The resident would go back and forth in her wheelchair in small little movements to attempt to get unstuck from the chair. Two staff members walked by this resident without assisting her. At 11:30 a.m., the resident was still attempting to get her wheelchair unstuck from the chair in the hallway when a facility staff member walked by and assisted the resident. On 08/28/14 at 7:00 a.m., Surveyor performed general observations on the dementia unit. When Surveyor entered the West side of the unit, two residents were seated at a long table. The unit was dark. Resident #12 was trying to read a newspaper. Surveyor asked CNA Y why the residents were seated at the table in the dark. CNA Y stated she "must have forgotten to turn the lights on." At 7:20 a.m., screaming could be heard from room [ROOM NUMBER]. Resident #1 was screaming, "Ow, ow, ow my back, my back." CNA Y went into room [ROOM NUMBER] and asked Resident #1 "What's the matter?" Resident #1 did not tell CNA Y that her back hurt. CNA Y told the resident that she would "be back in a little while to help you get up." CNA Y left room [ROOM NUMBER]. Surveyor asked CNA Y what her next step would be. CNA Y stated she would go tell the nurse. On 08/28/14 at 8:15 a.m., Surveyor interviewed CNA V. CNA V stated the residents on the dementia unit do not get the much needed 1:1 cares that are required because they are too busy. CNA V stated the unit is understaffed and they are lucky if they get three CNAs to assist on the unit. CNA V stated the unit has too many residents with behaviors and the staff are not able to take care of them. CNA V stated the staff have expressed their concerns on multiple occasions to the DON and Nursing Home Administrator (NHA) and they keep being told, "We'll look into it." CNA V stated nothing has been done so she feels the DON and NHA have not looked into all the concerns. On 08/28/14 at 8:15 a.m., Surveyor interviewed CNA W. CNA W stated the unit was understaffed and "1:1 with the residents is not going to happen." CNA W stated she has addressed her concerns with the DON and NHA but feels nothing has been done. CNA W stated management does not come to the unit to help out. CNA W stated, "We can only do the best we can do...we are on our own back here." On 08/28/14 at 10:05 a.m., Surveyor interviewed Activity Supervisor (AS) N discussing above mentioned concerns. AS N stated the facility does have an activity aide that works on the dementia unit five days a week, Monday through Friday, and every other Saturday. AS N the activity aide is on the unit Monday to Friday from 10:00 - 12:00 and then goes back at 2:30 to offer juice and snacks. AS N stated the activity aide is currently on vacation and there is no one to replace her when she is gone. AS N stated nursing staff do not offer activities on the unit because they are too busy. AS N stated she felt there were not enough staff to meet the needs of the residents on the dementia unit. AS N stated she has addressed this concern with both the DON and NHA and feels that nothing has been done. AS N stated management does not come to the dementia unit to assist staff and feels they should be helping more. AS N stated they do not have activities on Sundays because they do not have any staff member who can do it and floor staff can't do it because they are too busy. AS N stated she feels this is a big concern for the residents on the dementia unit and feels they are not having their needs met appropriately. Surveyor did not observe social services staff on the unit providing 1:1 social interactions with the residents within the dementia unit during all observation times. On 08/28/14, Surveyor interviewed the NHA and DON, discussing the above mentioned concerns. No further information was provided.

Based on record review and interviews, the facility did not immediately consult with the physician when there was a significant change in condition for 1 of 3 residents sampled who were reviewed as examples for notification. Resident #1 experienced a weight gain of five pounds in one day with a physician order [REDACTED]. Facility staff did not immediately consult with the physician on 06/26/10 or on 06/27/10 when weight gain was increased above physician notification parameters and did not immediately consult with the physician on 06/27/10 when blood was noted in the stool. This is evidenced by the following: Resident #1 was admitted to the facility on [DATE]. physician progress notes [REDACTED]. The physician progress notes [REDACTED]. It was also identified that Resident #1, at that time, had severe [MEDICAL CONDITION] involving the abdomen, buttocks, thighs and ankles with skin breakdown of the legs positive for [MEDICAL CONDITION]-Resistant Staphylococcus Aureus (MRSA). It was noted Resident #1 lost 60 pounds over four days of receiving a [MEDICATION NAME] drip while hospitalized (with a current weight of 174 pounds). On 05/28/10, current medications included insulin, [MEDICATION NAME] ([MEDICATION NAME]) and [MEDICATION NAME] (both diuretics) and [MEDICATION NAME] to be continued (three days a week) through 07/05/10 (for [MEDICAL CONDITION]). [MEDICATION NAME] was increased on 05/28/10 from 300 to 320 milligrams (mg) daily. It was stated Resident #1 would require close monitoring and close follow-up (including the [MEDICAL CONDITION] and renal function, the blood count, lower extremity [MEDICAL CONDITION] and "...monitor his weight closely...") Resident #1's Resident Assessment Instrument (RAI), completed 05/26/10, identified the resident had mild cognitive impairment and required limited staff assistance with most activities of daily living (ADLs). Resident #1's physician orders, current as of 06/20/10, identified weights were to be done daily and the physician was to be called if there was greater than a two or three pound weight gain overnight or a three to five pound weight gain in a week. Weight records for Resident #1 identified his weight progressively increased in June 2010, reaching 190 pounds on 06/09/10, 200 pounds on 06/16/10 (physician contacted) and 205 pounds on 06/25/10 (physician contacted). A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 06/26/10, nurses' notes identified Resident #1's weight increased to 210 pounds, a five pound increase from the previous day. A nurse's note, written by Licensed Practical Nurse (LPN) A at 11:23 p.m. identified Resident #1 had a fluctuation in weight from 198 to 210 pounds. Vital signs were not monitored. There was no evidence in the record the physician was consulted regarding the five pound weight increase. Surveyor interviewed LPN A on 09/02/10 at 4:10 p.m. LPN A stated resident weights were normally taken in the morning and she would have expected the nurse working the day shift to have notified the physician of Resident #1's weight gain on 06/26/10. On 06/27/10, a nurse's note written by LPN B at 2:29 a.m. stated, "diarrhea, loose, dark, foul smelling stools tonight. Trace amount of blood noticed with bowel movements. Continue to monitor and will offer [MEDICATION NAME] with loose stool..." Vital signs were not monitored. Nurses' notes written by Registered Nurse (RN) C at 2:00 p.m. identified Resident #1's weight remained at 210 pounds and a note at 2:02 p.m. stated loose stools continued, [MEDICATION NAME] was given and the information related to loose stools would be passed on to the oncoming shift. Vital signs were not monitored. There was no evidence in the record that the physician was consulted regarding the weight gain or the blood in the continued loose/diarrhea stools. LPN B was unavailable for interview. RN C no longer works at the facility and was unavailable for interview. Surveyor reviewed the facility's policy and procedure for physician notification/consultation parameters, last revised January 2010. The policy/procedure included the following (immediate notification and consultation was to occur no later than one hour after the condition was identified): -immediate notification/consultation required for bloody stools not due to hemorrhoids; -immediate notification/consultation required for acute onset of loose, watery stools (two or more episodes with 24 hours) with changes in vital signs. Resident #1 was known to be an insulin-dependent diabetic and experienced a condition change on 06/28/10 when he was found unresponsive with shallow breathing and periods of apnea (when the ambulance arrived, emergency medical personnel identified a low blood sugar of 29 and provided immediate treatment). The resident was transported to the local hospital and then on to a larger hospital where [DIAGNOSES REDACTED]. Surveyor interviewed the Director of Nursing (DON) on 09/02/10 at 2:00 p.m. who confirmed nurses were responsible to follow the policy and procedure for physician notification. On 06/28/10, Resident #1's emergency room records identified the resident was transported by helicopter to a larger hospital. Upon arrival there, the resident was again evaluated in the emergency room . Fresh frozen plasma was given (for low hemoglobin) and blood was ordered. Subsequently, guiac positive stools were identified with no report from the nursing home of Resident #1 having had any blood in the stool. It was noted there was a history of [MEDICAL CONDITION] and "The patient bleeds whenever his INR gets supra-therapeutic." Resident #1 was transferred to the critical care unit for further evaluation and treatment. Resident #1 was hospitalized until 07/01/10 and the discharge summary included the following Diagnoses: [REDACTED]. Surveyor interviewed Attending Physician (AP) E on 09/02/10 at 2:45 p.m. AP E stated he would have expected facility staff to contact a physician when they noted blood in Resident #1's stool and also to follow the physician order [REDACTED]. Surveyor interviewed Physician F on 09/02/10 at 7:30 p.m. who was the admitting physician at the larger hospital. Physician F stated that if the resident was taking in excessive water and/or gaining weight, then it would have been important to increase his water pills (to keep fluid from accumulating in vital organs and to keep his heart from having to work so hard).

Based on observation, interviews and record review, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial wellbeing to 1 of 3 residents who had a significant condition change. Resident #1 experienced a condition change on 06/26/10 when he was noted to have a weight gain of five pounds from the previous day with a physician order [REDACTED]. Resident #1 experienced a condition change on 06/27/10 when he was noted to have a persistent weight gain of five pounds, continued diarrhea stools with a trace amount of blood and an evening blood sugar requiring an increased amount of sliding scale insulin (third time in the last five days). Facility staff did not adequately monitor vital signs nor notify the physician in a timely manner regarding the weight gain, the blood in the continued loose/diarrhea stools and the need for recent increased sliding scale insulin in the evening. Resident #1 was known to be an insulin-dependent diabetic and experienced a condition change on 06/28/10 when he was found unresponsive with shallow breathing and periods of apnea (when the ambulance arrived, emergency medical personnel identified a low blood sugar of 29 and provided immediate treatment). Facility staff did not check the resident's blood sugar in order to provide immediate treatment if the blood sugar was found to be abnormal. Subsequently, the resident was transported to the local hospital and then on to a larger hospital where [DIAGNOSES REDACTED]. This is evidenced by the following: Resident #1 was admitted to the facility on [DATE]. physician progress notes [REDACTED]. The physician progress notes [REDACTED]. It was also identified Resident #1, at that time, had severe [MEDICAL CONDITION] involving the abdomen, buttocks, thighs and ankles with skin breakdown of the legs positive for [MEDICAL CONDITION] (MRSA). It was noted Resident #1 lost 60 pounds over four days of receiving a [MEDICATION NAME] drip while hospitalized (with a current weight of 174 pounds). On 05/28/10, current medications included [MEDICATION NAME] 18 units every morning and sliding scale insulin (four times a day), [MEDICATION NAME] ([MEDICATION NAME]) and [MEDICATION NAME] (both diuretics) and [MEDICATION NAME] to be continued (three days a week) through 07/05/10 (for [MEDICAL CONDITION]). [MEDICATION NAME] was increased on 05/28/10 from 300 to 320 milligrams (mg) daily. It was stated Resident #1 would require close monitoring and close follow-up (including the need for insulin changes related to elevated blood sugars, the [MEDICAL CONDITION] and renal function, the blood count, lower extremity [MEDICAL CONDITION] and "...monitor his weight closely..." Resident #1's Resident Assessment Instrument (RAI), completed 05/26/10, identified the resident had short-term memory problems, mild cognitive impairment, communication deficits and required limited staff assistance with most activities of daily living (ADLs). Resident #1's record included a code status document that identified he was a full code. Resident #1's physician orders [REDACTED]. Weight records for Resident #1 identified his weight progressively increased in June 2010, reaching 190 pounds on 06/09/10 and 200 pounds on 06/16/10. Nurses' notes identified the physician was contacted on 06/16/10 related to noncompliance (with the fluid restriction) and the weight gain. On 06/21/10, Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 06/24/10, nurses' notes identified Resident #1 twice had "diarrhea...all over himself and the floor" with [MEDICATION NAME] given. On 06/25/10, nurses' notes identified Resident #1's weight increased (from 198 on 06/24/10) to 205. The notes identified the physician was appropriately notified of the weight gain. It was also stated that on 06/25/10 Resident #1 had a large, loose, "dark" stool, with a foul odor and [MEDICATION NAME] was given. The MAR indicated [REDACTED]. On 06/26/10, nurses' notes identified Resident #1's weight increased to 210 pounds, a five pound increase from the previous day. A nurse's note, written by Licensed Practical Nurse (LPN) A at 10:13 p.m. stated Resident #1 was experiencing weakness and fatigue with exertion as well as non-[MEDICAL CONDITION]. LPN A's note at 11:23 p.m. identified Resident #1 had a fluctuation in weight from 198 to 210 pounds. There was no evidence in the record Resident #1 was adequately monitored to include vital signs, and the physician was not notified of the five pounds weight increase. Surveyor interviewed LPN A on 09/02/10 at 4:10 p.m. LPN A stated resident weights were normally taken in the morning and she would have expected the nurse working the day shift to have notified the physician of Resident #1's weight gain on 06/26/10. LPN A stated Resident #1's weakness noted on 06/26/10 was not new; he was maintaining so much fluid and had been having increased weakness. LPN A stated Resident #1 had [MEDICAL CONDITION] "all over." LPN A recalled Resident #1 had been having persistent loose stools and stated she had asked the nurse working the day shift about them. LPN A stated the day nurse attributed the loose stools to the antibiotics he was taking at the time. On 06/27/10, a nurse's note written by LPN B at 2:29 a.m. stated, "diarrhea, loose, dark, foul smelling stools tonight. Trace amount of blood noticed with bowel movements. Continue to monitor and will offer [MEDICATION NAME] with loose stool..." Nurses' notes written by Registered Nurse (RN) C at 2:00 p.m. identified Resident #1's weight remained at 210 pounds and a note at 2:02 p.m. stated loose stools continued, [MEDICATION NAME] was given and the information related to loose stools would be passed on to the oncoming shift. The MAR indicated [REDACTED]. There was no evidence in the record Resident #1 was adequately monitored to include vital signs, nor that staff ensured he received and consumed a bedtime snack. The physician was not notified regarding the weight gain, the blood in the continued loose/diarrhea stools or the need for the recent increased sliding scale insulin in the evening. LPN B was unavailable for interview. RN C no longer works at the facility and was unavailable for interview. Surveyor interviewed the Director of Nursing (DON) on 09/02/10 at 2:00 p.m. who stated all residents were offered a bedtime snack. The DON was unable to provide a policy/procedure related to bedtime snacks for diabetics that would ensure staff monitored diabetic residents received and consumed an evening snack. Surveyor reviewed the facility's policy and procedure for physician notification, last revised January 2010. The policy/procedure included the following (immediate notification was to occur no later than one hour after the condition was identified): -immediate notification required for bloody stools not due to hemorrhoids; -immediate notification required for acute onset of loose, watery stools (two or more episodes with 24 hours) with changes in vital signs. On 06/28/10, nurses' notes written by LPN B identified that at 2:42 a.m., Resident #1's oxygen saturation was 94% on room air and at 5:41 a.m., he had taken in no fluid intake (not abnormal to have had no fluid intake compared to documentation for other nights). Ongoing charting by RN D for 06/28/10 identified RN C had checked Resident #1's blood sugar at 7:00 a.m. when the dressing change was done (to the lower extremities). It was stated the blood sugar was 93 and Resident #1 appeared asleep at the time. RN D identified she was called to Resident #1's room at approximately 8:15 a.m. (before the resident's breakfast per record review) and found the resident to be unresponsive. Vital signs identified a temperature of 99.2 degrees, a pulse of 67 (thready), respirations at 26 (shallow with episodes of apnea) and a blood pressure of 110/48. Oxygen saturation was noted to be 80% on room air and oxygen was initiated at two liters per nasal cannula. There was no evidence in the record that a recheck of the oxygen saturation was done to ensure Resident #1's oxygen saturation increased when the oxygen was initiated. There was no evidence in the record that a blood sugar was done. It was identified the resident's abdomen was distended and he had been noted to have had a large amount of loose stool that morning. It was identified a call was placed to the physician and an order received to transport Resident #1 to the hospital by ambulance. It was identified the emergency medical system (EMS) was called. Surveyor interviewed RN D on 09/08/10 at 11:15 a.m. regarding no recheck of Resident #1's blood sugar on the morning of 06/28/10. RN D identified she was working as charge nurse on the morning of 06/28/10 and she was called to Resident #1's room by a Certified Nursing Assistant (CNA). RN D stated RN C was the nurse caring for Resident #1 that day, but added she was passing her medications at the time. RN D stated she "didn't think about the blood sugar until after the fact when the resident had already left the building." RN D stated she instructed a CNA to check with RN C about the blood sugar. RN D stated she thought RN C had taken it more recently than 7:00 a.m. RN D stated she "failed to repeat a blood sugar check" for Resident #1 on the morning of 06/28/10. When asked if there was any facility-wide training specific to this incident after it occurred, RN D stated RN C, another nurse and herself talked about the importance of taking blood sugars timely. RN C stated she did not recall the DON talking with her about the incident nor doing any facility-wide training. RN D contacted Surveyor on 09/08/10 at 11:35 a.m. regarding her previous interview. RN D stated that after thinking about the previous interview, she decided that, "knowing his blood sugar was 93 at 7:00 a.m. and being aware of his other underlying medical conditions, I would not necessarily have rechecked a blood sugar at 8:15 a.m." When Surveyor asked RN D to confirm that even though she was aware Resident #1 was a diabetic and was found unconscious, she would not have rechecked his blood sugar, she confirmed the statement. Surveyor reviewed the EMS documentation regarding Resident #1's transport on 06/28/10 from the facility to the hospital. It was identified the EMS dispatch time was 8:18 a.m. and they arrived to Resident #1 at 8:26 a.m. The following was also identified: the resident was unresponsive but breathing; EMS was informed oxygen was initiated due to a low oxygen saturation of 80% and the resident was a diabetic; a non-rebreather (mask) was applied at 12 liters; a blood glucose check was performed with a reading of 29; [MEDICATION NAME] 1 mg was injected; the resident's airway was suctioned; a repeat blood glucose check identified still a low reading of 28; [MEDICAL CONDITION] was noted; oxygen was increased to 15 liters. It was noted the ambulance arrived at the local hospital at 8:48 a.m. Surveyor reviewed the facility's policy and procedure for diabetic blood sugar monitoring, last revised April 2009. The policy/procedure included, "It is the policy of this facility that blood sugars will be measured and recorded on diabetics per MD (physician) orders or when symptomatic." Surveyor interviewed the DON on 09/02/10 at 2:00 p.m. who confirmed nurses were responsible to follow the policy and procedure for physician notification and diabetic blood sugar monitoring. On 06/28/10, Resident #1's emergency room records identified the resident presented to the local hospital still unresponsive, still hypoglycemic (blood sugar 28) 20 minutes after receiving the [MEDICATION NAME] and hypotensive (blood pressure 79/44). Resident #1 was also identified in the emergency room with a supratherapeutic INR, a new elevated creatinine, [MEDICAL CONDITION] (on arterial blood gases), an abdominal aortic aneurysm advanced in size, abdominal ascites and bilateral pleural effusions. Two doses of [MEDICATION NAME] were required to raise the blood sugar and Resident #1 was transported by helicopter to a larger hospital. Upon arrival there, the resident was again evaluated in the emergency room . Fresh frozen plasma was given (for low hemoglobin) and blood was ordered. Subsequently, guiac positive stools were identified with no report from the nursing home of Resident #1 having had any blood in the stool. It was noted there was a history of [MEDICAL CONDITION] and "The patient bleeds whenever his INR gets supra-therapeutic." Resident #1 was transferred to the critical care unit for further evaluation and treatment. Resident #1 was hospitalized until 07/01/10 and the discharge summary included the following Diagnoses: [REDACTED].; supratherapeutic INR present at the time of admission, resolved; and acute [MEDICAL CONDITION] at the original local emergency room of unclear etiology. Surveyor interviewed Attending Physician (AP) E on 09/02/10 at 2:45 p.m. AP E stated he would have expected facility staff to contact a physician when they noted blood in Resident #1's stool and also to follow the physician order [REDACTED]. Surveyor interviewed Physician F on 09/02/10 at 7:30 p.m. who was the admitting physician at the larger hospital. Physician F stated Resident #1 is not a simple or normal diabetic in that his blood sugar drops lower and faster than the normal diabetic. Physician F stated the resident's diabetes was more dangerous because he had less signs or symptoms (than the normal diabetic) with a low blood sugar. Physician F stated Resident #1 passed out from the low blood sugar on 06/28/10 and had a mild [MEDICAL CONDITION] probably due to not getting enough oxygen to the heart when he passed out. Physician F stated getting to the hospital sooner probably would not have prevented the [MEDICAL CONDITION], but added that with the low blood sugar of 29 the resident could have gone into an irreversible coma within approximately 30 minutes.