Every finding on record at Rivercrest Post Acute

Based on observation, interview, and record review it was determined the facility failed to provide supervision to prevent elopement for 1 of 3 sampled residents (#6) reviewed for accidents. This placed residents at risk for elopement. Findings include: Resident 6 admitted to the facility on [DATE] with diagnoses including post motor vehicle accident, stimulant abuse with intoxication and aphasia (a disorder that affects how you communicate).A 6/19/26 facility Elopement Risk Evaluation completed at the time of admission revealed Resident 6 was risk to wander. The evaluation revealed the resident wandered in the past month and tried to leave the facility alone without signing out. A 6/22/26 care plan indicated Resident 6 was an elopement risk; staff were to allow wandering in safe areas within the facility, attempt to refocus when exhibiting behaviors, and educate on use of the facility check in/check out log. The 6/24/26 admission MDS revealed Resident 6 had a BIMS score of 8 (moderate cognitive impairment).A 7/20/26 Elopement Investigation indicated Resident 6 eloped from the facility on 7/20/26. The resident was missing for approximately 10 minutes and was found on a main street near the facility. Prior to the elopement Resident 6 was agitated and pacing back and forth, and made statements of wanting to leave the facility. It was determined Resident 6 exited the facility through an improperly latching magnetic door at the perimeter of the facility.Observations made from 7/28/26 to 7/30/26 revealed Resident 6 with one-on-one supervision with her/him at all times. No other residents were observed making any attempts to elope from the facility. On 7/28/26 at 12:11 PM Staff 3 (Restorative Aide) stated Resident 6 was agitated all morning on 7/20/26, stating she/he wanted to leave the facility. Staff 3 stated she tried to redirect Resident 6 with snacks or with calling her/his family but the resident refused. Staff 3 stated she saw Resident 6 standing at the nurses station, looking very agitated, and then she saw the resident walk toward her/his room. Staff 3 stated she went to the resident's room but did not see the resident. She walked out to the smoking area in the enclosed courtyard, which required a door code, and did not see Resident 6. Staff 3 stated she noticed a side fence gate slightly open and went out to look for Resident 6 but did not see her/him, so she notified the nursing staff.On 7/29/26 at 2:11 PM Staff 6 (LPN) stated Resident 6 was antsy and tried to go outside on 7/20/26. Staff 6 stated Resident 6 was redirected to the outdoor fenced in area. Resident 6 told staff she/he wanted to run away and did not enjoy being at the facility. Staff 6 stated she did not know how Resident 6 got outside of the fenced area. Staff 6 stated she and Staff 2 (DNS) drove around for 10 minutes and found Resident 6 about one block away from the facility at a bus stop on the main road with a bag of her/his belongings.On 7/30/26 at 8:45 AM a staff member was observed to go through the back fence gate without inputting a code.On 7/30/26 at 8:55 AM a staff member was observed to go through the back fence gate without inputting a code. On 7/30/26 at 11:40 AM Staff 18 (Maintenance Director) stated on 7/20/26 the landscapers were working and might have forgotten to close the gate. Staff 18 stated he was in the process of installing stronger magnets on the gate. Staff 18 stated he was working on the locks and gate all week while waiting for the supplies to arrive and acknowledged there were some times when the gate was not locked. On 7/30/26 at 12:42 PM Staff 2 acknowledged Resident 6 eloped the facility. Staff 2 stated Resident 6 was placed on one on one supervision after the incident and the facility was in the process of educating staff and securing the fence.

Based on observation, interview, and record review it was determined the facility failed to investigate the root cause of resident falls for 8 of 10 sampled fall investigations and the facility failed to ensure safety interventions were in place to prevent smoking related accidents for 1 of 6 sampled residents (#7) reviewed for accidents. This placed residents at risk for further falls and smoking injuries. Findings include: 1. Resident 4 was admitted to the facility in 10/2025 with diagnoses including seizures and dementia. On 2/9/26 at 10:35 AM, Resident 4 stated she/he had a lot of falls due to self-transferring when she/he was tired of lying in bed. A 12/27/25 facility investigation indicated on 12/11/25 Resident 44 was found on the floor in the dining room. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 12/27/25 facility investigation indicated on 12/12/25 Resident 44 was found on the floor in her/his room. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 12/27/25 facility investigation indicated on 12/18/25 Resident 44 was found on the floor in her/his room. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 12/27/25 facility investigation indicated on 12/20/25 Resident 44 fell while standing using the urinal. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 12/27/25 facility investigation indicated on 12/23/25 Resident 44 was found on the floor in her/his room. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 2/3/26 facility investigation indicated on 1/29/26 Resident 44 was found on the floor in her/his room. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 2/3/26 facility investigation indicated on 1/29/26 Resident 44 was found on the floor in her/his room a second time. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. A 2/3/26 facility investigation indicated on 2/2/26 Resident 44 was found on the floor in her/his room. The investigation did not include an analysis of the root cause of the fall, or whether care planned interventions were effective, or if any additional interventions were put in place. On 2/13/26 at 10:59 AM, Staff 5 (Regional Director of Clinical Services), stated the fall investigations were not thorough, were missing the root cause analysis for the falls, and interventions were not put in place to help prevent further falls or help prevent injuries from falls. 2. The facility's 9/2024 Smoking Policy indicated the following: All smoking materials, including cigarettes, electronic cigarettes and lighters were to be locked up. Resident 7 admitted to the facility in 10/2024 with diagnoses including sepsis (the body's response to an extreme infection). A 1/8/26 Quarterly MDS indicated Resident 7 was cognitively intact. A 1/24/26 Care Plan indicated Resident 7 was assessed to be safe and independent while smoking and had to store her/his smoking supplies at the nurse's station. Multiple observations from 2/9/26 through 2/13/26 revealed Resident 7 had her/his lighter on the bedside table. On 2/11/26 at 8:18 AM Resident 7 stated she/he passed the facility assessment and was allowed to smoke at any time, and was able to keep smoking supplies in her/his room. Resident 7 stated she/he did not receive a lock box to secure the smoking supplies. On 2/11/26 at 8:56 AM Staff 12 (CNA) stated the facility had residents who required supervision while smoking, as well as residents who were cleared to smoke independently. Staff 12 stated residents who required supervision while smoking had to leave their smoking supplies in a secured lock box at the nurse's station and the residents who were able to smoke independently were allowed to keep their smoking items in their room. Staff 12 denied knowing if residents had locked boxes in their rooms. On 2/11/26 at 2:38 PM Staff 10 (LPN) stated the smoking policy required all residents to return smoking items to the nurse's station between each smoke break. Staff 10 stated he was aware of times when Resident 7 failed to return her/his lighter to the nurse's station after smoking. Staff 10 stated the resident never experienced any smoking related accidents and was able to make safe decisions related to smoking. On 2/12/26 at 10:52 AM Staff 1 (Administrator) stated the residents who were identified as smokers were expected to store all smoking supplies in a secured box at the nurse's station or in a personal lock box in their rooms. Staff 1 and the surveyor observed Resident 7 with a lighter on her/his bedside table and Staff 1 acknowledged the lighter was not stored in a secure manner.

Based on interview and record review it was determined the facility failed to ensure advance directives were offered or obtained for 4 of 4 sampled residents (#s 4, 22, 25, and 26) reviewed for advance directives. This placed residents at risk for personal health care choices not being honored. Findings include: 1. Resident 4 was admitted to the facility in 10/2025 with diagnoses including liver failure and heart disease. A 10/28/25 care plan indicated Resident 4 had an advance directive. A review of Resident 4's medical record revealed no evidence of an advance directive. On 2/10/26 at 2:56 PM, Resident 4 stated she/he had an advance directive, but no one in the facility asked her/him about it. On 2/10/26 at 3:12 PM, Staff 7 (Social Service Director) acknowledged Resident 4 was not asked about an advance directive. Staff 7 stated the process was to ask residents if they had an advance directive upon admission, and if they did not have one, staff were to offer an advance directive at admission and periodically throughout their stay. 2. Resident 26 was admitted to the facility in 11/2025 with diagnoses including acute respiratory failure and heart failure. A 12/8/25 revised care plan indicated Resident 26 had an advance directive for full code status with full treatment. A review of Resident 26's medical record revealed no evidence of an advance directive. On 2/10/26 at 2:53 PM, Resident 26 stated she/he did not have an advance directive, was not offered to complete one, and Resident 26 stated she/he was interested in completing an advance directive. On 2/10/26 at 3:12 PM, Staff 7 (Social Service Director) acknowledged Resident 26 was not offered an advance directive. Staff 7 stated the process was to ask residents if they had an advance directive upon admission and if they did not have one, staff were to offer an advance directive at admission and periodically throughout their stay. 3. Resident 22 was admitted to the facility in 12/2025 with diagnoses including diabetes and depression. A review of Resident 22's medical record revealed no indication the resident was asked if she/he had an advance directive or was offered a blank form to complete. On 2/10/26 at 3:01 PM Resident 22 stated the facility never discussed her/his wishes and she/he was not offered an advance directive. On 2/10/26 at 3:12 PM Staff 7 (SSD) stated Resident 22 was not offered an advance directive upon admission to the facility and there was no follow up since admission. 4. Resident 25 admitted to the facility in 12/2025 with a diagnosis of osteomyelitis (bone infection). A 12/22/25 admission MDS revealed Resident 25 had a BIMS of 15 which indicated she/he was cognitively intact. A 12/23/25 care plan revealed Resident 25 had an advance directive for full code status. A review of Resident 25's medical record revealed no information related to an advance directive. On 2/10/26 at 1:44 PM Resident 25 stated she/he had advance directive paperwork at home and the facility did not ask her/him to provide it to the facility. On 2/10/26 at 2:05 PM Staff 7 (SSD) stated the advance directive information on Resident 25's care plan referred to her/his POLST and she was unaware Resident 25 had an advance directive at home.

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 2 of 5 sampled CNA staff (#s 15, 16, and 17) reviewed for sufficient and competent nurse staffing. This placed residents at risk for a lack of competent staff. Findings include:A review of personnel records indicated the following employees did not receive their annual performance evaluations:-Staff 15 (CNA), hire dated was 4/9/22 and a performance review was not completed.-Staff 16 (CNA), hire date was 1/17/22 and a performance review was not completed.-Staff 17 (CNA), hire date was 10/1/13 and a performance review was not completed.On 2/12/26 at 2:26 PM Staff 3 (Assistant Director of Clinical Services) confirmed annual performance reviews for Staff 15, Staff 16, and Staff 17 were not completed.

Based on interview and record review it was determined the facility failed to provide a recapitulation of the resident's stay at the time of discharge for 3 of 3 sampled residents (#s 61, 62, and 63) reviewed for Beneficiary Notification Review. This placed residents at risk for lack of knowledge regarding their care and treatment provided during their stay at the facility. Findings include: 1. Resident 61 was admitted to the facility in 12/2025 with diagnoses including sepsis and cellulitis.A review of Resident 61's medical record revealed she/he discharged from the facility on 1/8/26 and there was no indication a written recapitulation of Resident 61's stay was completed and provided to the resident at the time of discharge.On 2/12/26 at 10:42 AM Staff 3 (Assistant Regional Director of Clinical Services) stated at the time of discharge facility staff provided verbal education, a printed copy of the physician orders, lab results as applicable, a printed progress note, and home health details.On 2/13/26 at 12:07 PM Staff 5 (Regional Director of Clinical Services) stated a recapitulation was not completed and provided to Resident 61 at discharge. 2. Resident 62 was admitted to the facility on [DATE] with diagnoses including pneumonia and adult failure to thrive.A review of Resident 62's medical record revealed she/he discharged from the facility on 9/30/25. There was no indication a written recapitulation of Resident 62's stay was completed and provided to the resident at the time of discharge.On 2/12/26 at 10:42 AM Staff 3 (Assistant Regional Director of Clinical Services) stated at the time of discharge facility staff provided verbal education, a printed copy of the physician orders, lab results as applicable, a printed progress note, and home health details.On 2/13/26 at 12:07 PM Staff 5 (Regional Director of Clinical Services) stated a recapitulation was not completed and provided to Resident 62 at discharge. 3. Resident 63 was admitted to the facility on [DATE] with diagnoses including diabetes and muscle weakness. A review of Resident 63's medical record revealed she/he discharged from the facility on 10/2/25. There was no indication a written recapitulation of Resident 63's stay was completed and provided to the resident at the time of discharge.On 2/12/26 at 10:42 AM Staff 3 (Assistant Regional Director of Clinical Services) stated at the time of discharge facility staff provided verbal education, a printed copy of the physician orders, lab results as applicable, a printed progress note, and home health details.On 2/13/26 at 12:07 PM Staff 5 (Regional Director of Clinical Services) stated a recapitulation was not completed and provided to Resident 63 at discharge.

Based on observation and interview it was determined the facility failed to provide a private space for resident council meetings for 1 of 1 resident council group reviewed for privacy. This placed residents at risk for a lack of participation in group discussions regarding facility policies, procedures and resident rights. Findings include:On 2/11/26 at 12:35 PM a resident council meeting was held in the facility dining room with state surveyors and eleven residents. The dining room was located next to the therapy gym with only a thin plastic room divider between the two rooms. The therapy gym had only one entrance and exit which required staff to pass through the dining area to get residents to and from therapy.On 2/11/26 between the times of 12:35 PM and 1:05 PM observations of the resident council meeting revealed the following:-Staff and other residents repeatedly entered the dining area in order to get to the therapy gym which caused the resident council meeting to pause.-Conversations between staff and other residents were heard from the therapy room and hallway which created a disruptive environment, and indicated a lack of privacy during the resident council meeting. -Staff entered the dining area in order to get coffee and supplies for residents who were not a part of the resident council meeting.On 2/11/26 at 12:37 PM Resident 11 stated resident council was held in the dining area monthly, and privacy was always an issue. Resident 11 stated it was important for residents to feel they had privacy to discuss topics of concern without staff overhearing or being present which was not possible due to staff being unable to assist residents to the therapy gym without passing through the dining area where resident council was meeting.On 2/12/26 at 10:02 AM Staff 6 (Activities Director) stated she was aware of concerns related to privacy during resident council. Staff 6 stated before each resident council meeting, signage was posted to inform staff of the meeting taking place and she encouraged staff to respect the residents and their privacy during that time. Staff 6 stated it was often difficult to ensure the meeting proceeded without interruption due to the location of the dining area and the need to assist residents to and from the therapy gym.On 2/13/26 at 12:16 PM Staff 1 (Administrator) stated he was aware of the lack of privacy residents had during their monthly resident council meetings and acknowledged no other measures were taken to ensure the residents had privacy during that time.

Based on observation, interview and record review it was determined the facility failed to ensure residents received treatment and care for a catheter for 1 of 1 sampled resident (#25) reviewed for urinary catheter. This placed residents at risk for urinary tract infections. Findings include: Resident 25 admitted to the facility in 12/2025 with diagnoses including osteomyelitis (bone infection) and neurogenic bladder (loss of bladder control). A 12/15/25 Nursing admission Assessment revealed Resident 25 admitted to the facility with a catheter in place.A 12/22/25 admission MDS revealed Resident 25 had an indwelling catheter in place. A review of Resident 25's physician orders revealed no orders related to the care of her/his indwelling catheter until 2/9/26.On 2/9/26 at 1:53 PM Resident 25 was observed with a catheter. Resident 25 stated she/he felt the facility did not provide required care for the catheter. On 2/10/26 at 2:54 PM Staff 19 (RN) stated physician orders were required to direct the nursing staff to provide care for catheters, including when to flush and change them. Staff 19 stated she did not change Resident 25's catheter and did not recall any issues with it.On 2/12/26 at 9:54 AM Staff 20 (LPN Resident Care Manager) stated Resident 25 admitted to the facility with a catheter in place, but the facility did not obtain orders to provide care for it until 2/9/26.

Based on interview and record review it was determined the facility failed to report allegations of abuse for 1 of 1 sample resident (#2) reviewed for abuse. This placed residents at risk for resident-to-resident abuse. Findings include: 1. Resident 2 was admitted to the facility in 5/2025 with diagnoses including anxiety and depression.Resident 43 was admitted to the facility in 10/2025 with diagnoses including traumatic brain injury and depression.A 11/8/25 Progress Note indicated Resident 2 was involved in a verbal altercation with Resident 43 and Resident 43 threatened to hit Resident 2 with her/his hand and with a box of gloves.A 11/8/25 written statement by Staff 23 (CNA) indicated Resident 43 rose her/his hand towards Resident 2 and Resident 2 expressed fear.Resident 2 was unable to be interviewed related to this incident due to cognitive impairment. On 2/11/26 at 11:51 AM, Staff 2 (DNS) acknowledged there was no investigation completed for the 11/8/25 altercation between Resident 2 and Resident 43 and stated the incident was not reported to the State Agency.On 2/11/26 at 1:35 PM, Staff 23 stated on 11/8/25 Resident 43 became upset with Resident 2 and Resident 43 raised her/his hand at Resident 2. Staff 23 stated Resident 2 flinched when Resident 43 raised her/his hand at Resident 2.On 2/13/26 at 10:49 AM Staff 5 (Regional Director of Clinical) stated the resident-to-resident incident described above should have been reported to the State Agency.2. Resident 2 was admitted to the facility in 5/2025 with diagnoses including anxiety and depression.Resident 43 was admitted to the facility in 10/2025 with diagnoses including traumatic brain injury and depression.On 2/11/26 at 11:51 AM, Staff 2 (DNS) provided an investigation for a 11/9/25 resident-to-resident altercation. Staff 2 stated abuse and neglect was immediately ruled out so the incident was not reported to the State Agency.Resident 43's 11/9/25 Progress Note written by Staff 24 (LPN) indicated Resident 43 kicked Resident 2 when Resident 2 would not give Resident 43 a cigarette.A 11/10/25 investigation indicated Staff 24 did not mean to chart Resident 43 kicked Resident 2. The investigation indicated Staff 24 witnessed the altercation from a distance and witnessed Resident 43 kick at Resident 2, but no physical contact was made.On 2/12/26 at 2:01 PM, Staff 24 stated on 11/9/25 there was an altercation between Resident 43 and Resident 2. Staff 24 stated she saw Resident 43's and Resident 2's wheelchairs bump into each other and Resident 2 stated Resident 43 hit her/him. Staff 24 stated the on-call nurse was notified of the incident.On 2/13/26 at 10:49 AM Staff 5 (Regional Director of Clinical) stated the identified resident-to-resident incident was not reported to the State Agency, but should have been reported.

Based on interview and record review it was determined the facility failed to investigate an allegation of abuse for 1 of 1 sampled resident (#2) reviewed for abuse. This placed residents at risk for continued abuse. Findings include:1. Resident 2 was admitted to the facility in 5/2025 with diagnoses including anxiety and depression.Resident 43 was admitted to the facility in 10/2025 with diagnoses including traumatic brain injury and depression.A 11/8/25 Progress Note indicated Resident 2 was involved in a verbal altercation with Resident 43 and Resident 43 threatened to hit Resident 2 with her/his hand and with a box of gloves.A 11/8/25 written statement written by Staff 23 (CNA) indicated Resident 43 rose her/his hand towards Resident 2 and Resident 2 expressed fear.Resident 2 was unable to be interviewed related to this incident due to cognitive impairment.On 2/11/25 at 11:51 AM, Staff 2 (DNS) stated there was no investigation completed for the 11/8/25 altercation between Resident 2 and Resident 43.On 2/11/26 at 1:35 PM, Staff 23 (CNA) stated on 11/8/25 Resident 43 became upset with Resident 2 and Resident 43 raised her/his hand at Resident 2. Staff 23 stated Resident 2 flinched when Resident 43 raised her/his hand at Resident 2.On 2/13/26 at 10:49 AM Staff 5 (Regional Director of Clinical) stated the 11/8/25 resident-to-resident incident should have been investigated.2. Resident 2 was admitted to the facility in 5/2025 with diagnoses including anxiety and depression.Resident 43 was admitted to the facility in 10/2025 with diagnoses including traumatic brain injury and depression.On 2/11/26 at 11:51 AM, Staff 2 (DNS) provided an investigation for a 11/9/25 resident-to-resident altercation. Staff 2 stated abuse and neglect was immediately ruled out so the incident was not reported to the state agency.Resident 43's 11/9/25 Progress Note written by Staff 24 (LPN) indicated Resident 43 kicked Resident 2 when Resident 2 would not give Resident 43 a cigarette.A review of Resident 2's medical record revealed no evidence of documentation related to an altercation with Resident 43. A 11/10/25 investigation indicated Staff 24 errantly documented that Resident 43 kicked Resident 2. The investigation indicated Staff 24 witnessed the altercation from a distance and witnessed Resident 43 kick at Resident 2, but no physical contact was made.On 2/12/26 at 2:01 PM, Staff 24 stated on 11/9/25 there was an altercation between Resident 43 and Resident 2. Staff 24 stated she saw Resident 43's and Resident 4's wheelchairs bump into each other and Resident 2 stated Resident 43 hit her/him. Staff 24 stated the on-call nurse was notified of the incident.On 2/13/26 at 10:49 AM Staff 5 (Regional Director of Clinical) stated the identified resident-to-resident incident was not investigated thoroughly.

Based on interview and record review it was determined the facility failed to accurately code an MDS assessment for 1 of 2 sampled residents (#1) reviewed for respiratory care. This placed residents at risk for unassessed needs. Finding include:Resident 1 was admitted to the facility in 9/2025 with diagnoses including cancer of the larynx and lungs.A 12/10/25 Physician Order revealed orders for oxygen as needed.A review of the 12/2025 MAR revealed Resident 1 received oxygen daily.A 12/10/25 Physician Order revealed orders to monitor for need for suctioning every four hours.A review of the 12/2025 MAR revealed documentation Resident 1 needed suctioning two to three times a day.A 12/20/25 Significant Change MDS indicated Resident 1 did not receive oxygen and did not need to be suctioned.On 2/12/26 at 1:26 PM, Staff 3 (Assistant Director of Clinical) stated Resident 1 received oxygen and suctioning during the look back period for the 12/20/25 Significant Change MDS. Staff 3 acknowledged the MDS was coded incorrectly.

Based on interview and record review it was determined the facility failed to develop a comprehensive care plan for 2 of 5 sampled residents (#s 22 and 28) reviewed for nutrition and pain. This placed residents at risk for unmet needs. Findings include:A review of the undated facility Comprehensive Person-Centered Care Plans policy revealed the following:-The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.-The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions.-Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 1. Resident 22 was admitted to the facility in 12/2025 with diagnoses including a wedge compression fracture of the lumbar (lower back), pain in an unspecified joint and opioid dependence.A review of the 12/31/25 admission MDS revealed Resident 22 had frequent pain and received scheduled and PRN pain medication. The Pain CAA revealed Resident 22 had chronic pain in her/his back that limited her/his day-to-day activities, participation in rehab therapy and disturbed her/his sleep. Staff were to encourage Resident 22 to turn and reposition for comfort and Resident 22's care plan would be developed to monitor pain management.A review of Resident 22's care plan revealed no indication the pain care plan was developed, and no goals or interventions were implemented to monitor the residents pain management.On 2/13/26 at 9:41 AM Staff 2 (DNS) stated Resident 22's pain care plan needed to be created upon admission and updated as staff became aware of any changes or new interventions. 2. Resident 28 was admitted to the facility on [DATE] with diagnoses including end-stage renal disease (ESRD) and malnutrition.A review of the 1/24/26 Nursing admission Evaluation and Assessment revealed Resident 28 received dialysis (a medical treatment that removes waste products from the blood when the kidneys are not working properly) treatments.A review of the 1/29/26 admission Nutritional Risk Assessment revealed Resident 28 was at nutritional risk related to malnutrition, was on a therapeutic diet, and there was potential for decreased intake related to ESRD with dialysis. It was noted Resident 28's weight fluctuations were expected to shift with dialysis treatments, and the resident would benefit from additional protein with meals.A review of the 1/31/26 admission MDS Nutritional Status CAA revealed Resident 28 was dependent on dialysis treatments, had a diagnosis of malnutrition and the nutrition care plan would be developed and updated as needed.A review of Resident 28's care plan revealed no indication the nutrition care plan was developed, and no goals or interventions were implemented related to the resident's diagnosis of malnutrition.On 2/13/26 at 10:01 AM Staff 4 (Assistant DNS/LPN) stated she oversaw Resident 28's comprehensive care plan, and it needed a nutrition care plan related to the risk for malnutrition. Staff 4 confirmed Resident 28 did not have a nutrition care plan.On 2/13/26 at 10:03 AM Staff 2 (DNS) stated she expected each resident's comprehensive care plan to be developed to include goals and interventions related to nutrition.

Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary antiplatelet medications for 1 of 1 sampled resident (#28) reviewed for dialysis. This placed residents at risk for adverse side effects. Findings include:Resident 28 was admitted to the facility on [DATE] with diagnoses including end-stage renal disease (ESRD) and acute embolism and thrombosis of deep veins in lower extremity (a blood clot forms inside a blood vessel then breaks off and travels through the bloodstream until it lodges in a narrower vessel).A review of the 1/24/26 Hospital Transfer orders revealed Resident 28 was to start Eliquis (an anticoagulant) on 1/24/26. Resident 28 was to then start Plavix (an antiplatelet) on 3/6/26. Special instructions stated to not take Plavix while on Eliquis.A review of the January 2026 MAR revealed Resident 28 started Eliquis on 1/24/26 per physician orders and continued receiving Eliquis through 2/9/26. The MAR also revealed on 1/28/26 an order for Plavix was entered and administered to Resident 28 starting on 1/29/26 and continuing through 2/9/26 (12 days).A 2/9/26 Progress Note indicated Resident 28 returned from a dialysis treatment with abnormal lab results and was sent to the Emergency Department (ED) to be evaluated.A 2/10/26 Progress Note indicated Resident 28 returned from the ED, had low hemoglobin lab results and the resident was told not to take Eliquis and Plavix together.On 2/11/26 at 4:00 PM Staff 10 (LPN) stated he entered the order for Plavix on 1/28/26 in error. A 2/13/26 Medication Error Incident Report revealed the 2/9/26 ED discharge orders indicated Resident 28 Plavix should have been held until Resident 28 was done taking Eliquis, but the Plavix was not held. On 2/13/26 at 9:59 AM Staff 2 (DNS) stated on 2/9/26 Resident 28 went to the ED due to abnormal lab results and it was found Resident 28 received Eliquis and Plavix together for 12 days. Staff 2 stated Plavix should have been held during the course of Eliquis, and it was not.

Based on observation, interview and record review it was determined the facility failed to store resident food in a sanitary manner for 1 of 1 resident refrigerator reviewed for food safety. This placed residents at risk for contamination and at risk for foodborne illness. Findings include:A review of the 9/1/24 Resident Food from Outside Source facility policy revealed the following:-Refrigerated food items from an outside source are stored in a container with the date it was received, name of product type, and resident name/room number.-Refrigerated products are discarded on the following schedule: homemade items, restaurant leftovers, take out items, milk, cottage cheese and similar type items are discarded on day three. During a review of the resident refrigerator located in the dining room on 2/12/26 at 3:50 PM, the following was found:-One clear plastic container that contained what appeared to be sliced peppers that were brown in color. It was labeled with a resident's name and dated 1/6/26 (stored 37 days).-A clump of thick brown creamy substance located on the ceiling of the refrigerator.-Sticky brown residue on the shelf of the door.On 2/12/26 at 3:55 PM Staff 9 (Dietary Manager) stated the resident refrigerator was cleaned weekly and as needed. Staff 9 stated it was the responsibility of the kitchen staff to clean and discard outdated food items. Staff 9 stated they followed the use by or sell by date, and any homemade items were discarded on day three. Staff 9 confirmed the condition of the refrigerator and the outdated food items. On 2/13/26 at 11:24 AM Staff 1 (Administrator) acknowledged the findings and stated he expected the resident refrigerator to remain clean.

Based on observation, interviews, and record review it was determined the facility failed to follow transmission-based precautions for 1 of 1 facility reviewed for infection control. This placed residents at risk for infection. Findings include:Resident 25 was admitted to the facility in 12/2025 with diagnoses including diabetes.On 2/9/26 at 11:47 AM Resident 25 was observed to have a urinary catheter in place, and Staff 20 (CNA) was observed transferring Resident 25 into her/his wheelchair without a gown on.On 2/9/26 at 12:02 PM, Staff 20 stated Resident 25 was on enhanced barrier precautions, and she should have worn a gown when transferring Resident 25 out of bed.On 2/11/25 at 1:19 PM Staff 4 (LPN Infection Preventionist/Assistant Director of Nursing) stated Resident 25 was on enhanced barrier precautions due to having a urinary catheter and wounds. Staff 4 stated when residents were on enhanced barrier precautions, staff were expected to wear gloves and a gown when providing direct patient care such as transferring residents out of bed.

Based on interview and record review it was determined the facility failed to complete a baseline care plan within 48 hours of a resident's admission for 1 of 1 sampled resident (#28) reviewed for dialysis. This placed residents at risk for dialysis access site complications. Findings include: The facility's Baseline Plan of Care policy, last updated 9/2024, indicated the following:-It is the policy of this facility that direct caregivers have accurate information available to them to properly care for their residents.-The licensed nurse completes the initial nursing database upon admission. The nurse collects information about the resident and their needs. Interventions are implemented and available on the plan of care for the CNA and other caregivers to review.The facility's Hemodialysis Care policy, last updated 9/1/24, indicated the following:-Care Plan interventions are individualized to the resident, but also include the following:a. No blood draws on access arm.b. No blood pressure readings on access arm - unless otherwise specified by dialysis center or physician as some allow.c. Emergency supplies kept at beside.d. Routine weight per medical provider order.Resident 28 was admitted to the facility on [DATE] with diagnoses including end-stage renal disease and diabetes.A review of the 1/24/26 Nursing admission Evaluation and Assessment revealed Resident 28 received dialysis (a medical treatment that removes waste products from the blood when the kidneys are not working properly) treatments.A review of the care plan revealed in the undated Special Instructions at the top of the care plan, Resident 28 received dialysis on Monday, Wednesday, and Fridays at 6:00 AM with transportation arriving at 5:00 AM. A care plan initiated on 1/28/26 (four days after admission) revealed Resident 28 required dialysis for end stage renal failure with a fistula to her/his left forearm and was at risk for bleeding at the access site, edema, hypertension and hypotension. Staff were to check the fistula site dressing upon return from dialysis.Resident 28's care plan did not include instructions related to blood draws, blood pressure, location of emergency supplies, or information about obtaining routine weights.On 2/13/26 at 9:43 AM Staff 4 (Assistant DNS/LPN) and Staff 2 (DNS) acknowledged Resident 28's baseline care plan did not adequately address the resident's care needs related to dialysis.

Based on interview and record review it was determined the facility failed to ensure survey results of the previous year were readily accessible for 1 of 1 facility reviewed for resident council. This placed residents and the public at risk for not being informed of the facility's survey history. Findings include:On 2/12/26 at 8:46 AM after the resident council meeting, Resident 37 stated she/he reviewed the survey results binder, and she/he noticed the survey results posted in the binder were from two years ago.On 2/12/26 at 9:16 AM the survey binder was observed near the entrance of the facility. The report from the facility's most recent survey was not found.On 2/12/26 at 10:52 AM Staff 1 (Administrator) acknowledged the most recent survey results were not included in the facility survey binder.

Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 6 sampled residents (#s 2 and 22) reviewed for medication. This placed residents at risk for adverse side effects. Findings include:1. Resident 2 admitted to the facility in 2025 with diagnoses including depression and adjustment disorder.The 1/29/25 Care Plan indicated Resident 2 experienced pain due to a recent surgery and motor vehicle accident with multiple fractures. Interventions included to administer medications as ordered.A 4/8/25 physician order indicate Resident 2 was to receive oxycodone 5 mg every four hours as needed for pain and 10 mg every four hours as needed for pain. The medication was not to exceed more than 40 mg daily.A 4/24/25 progress note indicated Staff 5 (LPN) signed out a dose of oxycodone and noted Resident 2 received 50 mg of Oxycodone on 4/23/25. The medication was to not exceed 40 mg per day. Resident 2 was notified and the on call provider was notified. Resident 2 was placed on alert.A 4/24/25 Medication Error report indicated Staff 5 signed out a dose of oxycodone and noted Resident 2 received 50 mg on 4/23/25. The order indicated not to exceed 40 mg per day.On 11/13/25 at 12:41 PM Staff 5 stated she recalled Resident 2 had an odd order related to pain medication. Staff 5 stated she could not recall the identified medication error and was unable to provide additional information.On 11/14/25 at 11:55 AM Staff 2 (DNS) acknowledged the findings of the medication error related to Resident 2 receiving excessive oxycodone.2. Resident 22 admitted to the facility in 2023 with diagnoses including depression.A 12/20/24 progress note indicated Resident 22 was approached with medications. Staff 15 (LPN) said the incorrect name to the resident. Resident 22 did not hear the wrong name and took the medication. Resident 22 was administered the medication in error. The provider was notified, and the resident was placed on alert for adverse side effects.The 12/20/24 Medication Error report indicated Resident 22 received her/his roommate's morning medication including 60 mg of duloxetine (antidepressant). Resident 22 indicated she/he felt fine.On 11/18/25 at 12:00 PM Staff 22 stated she was worked for a staffing agency and only worked in the facility for one or two shifts. Staff 22 stated on the day of the incident she asked Resident 22 if this was her/his name [roommate's name], and she/he stated yes. Staff 22 stated she told the resident she had her/his medication and the resident stated okay and took the medication. Staff 22 stated when she went to give medication to the roommate, she realized she gave Resident 22 the wrong medication. Staff 22 stated if she was not familiar with a resident and a picture was not available; she asked other staff where she could find the resident. Staff 22 acknowledged the identified medication error.On 11/18/25 at 11:18 AM Staff 1 (Administrator) acknowledged the identified medication error that occurred related to Resident 22.

Based on interview and record review it was determined the facility failed to ensure falls were evaluated to ensure resident safety and to ensure care plan interventions were followed for 2 of 4 sampled residents (#s 3 and 7) reviewed for accidents. This placed residents at risk for continued accidents. Findings include: 1. Resident 3 admitted to the facility in 11/2024, with diagnoses including heart failure. A 12/1/24 at 02:26 AM Progress Note indicated Resident 3 slid out of bed, landed on the floor and got a skin tear on her/his leg. The same progress note indicated Resident 3 was sent out to the hospital per her/his request, not due to injury. The resident did not return to the facility. The progress note did indicate if Resident 3's fall was witness or unwitnessed. Record review found no documented evidence to show the resident's fall was evaluated to ensure resident safety and care plan interventions were followed. On 4/18/25 at 10:15 AM, Staff 2 (DNS) and Staff 3 (RN consultant) confirmed that a thorough and complete analysis was not done for Resident 3's fall incident. 2. Resident 7 admitted to the facility 3/2025, with diagnoses including failure to thrive. Resident 7's 4/1/25 Un-witnessed Fall Investigation was incomplete. Resident 7 was unaware of any details of the incident. The analysis of the fall incident was not in the report and no evidence to show the resident's fall was evaluated to ensure resident safety and to ensure care plan interventions were followed. Review of Resident 7's clinical record indicated the resident's fall on 4/1/25 was not her/his first fall in the facility. On 4/18/25 at 10:15 AM, Staff 2 (DNS) and Staff 3 (RN consultant) confirmed that a thorough and complete analysis of the incident was not done for Resident 7's 4/1/25 fall.

Based on observation, interview and record review it was determined the facility failed to ensure staff followed contact precautions for 1 of 3 sampled residents (#1) reviewed for infection control. This placed residents at risk for cross contaminations. Findings include: Resident 1 was admitted to the facility on ,d+[DATE], with diagnoses including a stage 4 and stage 3 pressure ulcer. On 4/17/25 at 9:09 AM, Staff 4 (LPN) and Staff 5 (CNA) performed a dressing change for Resident 1. Staff 4 removed the old dressing and carefully cleaned Resident 1's wound. Staff then re-dressed the wound per physician order. Staff 4 did not change her gloves between handling soiled dressings and clean dressings. On 4/17/25 at 9:18 AM, Staff 4 (LPN) removed her PPE gown improperly. Staff 4 came into contact with the exterior side of the gown when it was removed. On 4/17/25 at 9:21 AM, Staff 4 (LPN) confirmed she was aware she should have changed her gloves between dirty and clean portions of the procedure. Staff 4 stated she understood the contamination risk related to how a PPE gown should be removed. On 4/18/25 at 10:15 AM, Staff 3 (RN consultant) and Staff 2 (DNS) stated the expectation was gloves were changed between dirty and clean portions of a dressing change. Staff 2 and Staff 3 also confirmed a PPE gown should not be removed over a person's head.

Based on interview and record review it was determined the facility failed to have the Medical Director attend the Quality Assessment and Assurance and Quality Assurance Performance Improvement (QAA/QAPI) committee meetings. This placed residents at risk for unidentified needs. Findings include: Documentation of QAA/QAPI meeting minutes were requested from 4/2024 through 9/2024 which revealed Staff 23 (Former Medical Director) did not attend any of the QAA/QAPI meetings. On 10/8/24 at 9:59 AM, and on 10/11/24 at 1:51 PM, Staff 1 (Administrator) stated Staff 23 the Former Medical Director refused to attend the QAA/QAPI meetings in person or via skype.

Based on interview and record review it was determined the facility failed to provide necessary care and services related to a resident who complained of difficulty breathing for 1 of 3 sampled residents (#1) reviewed for change in condition. This failure resulted in delayed activation of the emergency medical system (EMS) while the resident suffered from difficulty breathing. Findings include: Resident 1 was readmitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress Note dated 12/5/21 by Staff 3 (RN) indicated Resident 1 complained of shortness of breath and requested to be sent to the hospital. (The note did not include a thorough assessment by Staff 3 of the resident's condition related to difficulty breathing such as assessing lung sounds, heart sounds or rhythm, breathing rate or heart rate.) The resident had Witness 2 (Power of Attorney) call 911 for her/him and the resident was transferred to the hospital. (The note did not explain why Witness 2 called 911 instead of Staff 3.) The note indicated the Emergency Medical Technicians had a community nurse who could provide the resident education regarding appropriate uses and times for calling 911. (The note did not explain why the resident would benefit from such education.) A Hospitalist Progress Note dated 12/6/21 indicated Resident 1 was diagnosed at the hospital with acute respiratory failure including [CONDITION(S)] (the lack of enough oxygen in body tissues to sustain body functions) and hypercapnia (too much carbon [MEDICATION(S)] in the bloodstream typically caused by inadequate respiration). The resident was placed on a ventilator (mechanical breathing machine) attached to the resident's [CONDITION(S)]. The resident had wheezing coarse breath sounds. A hospital Discharge Summary dated 12/10/21 indicated EMS arrived at the facility and found Resident 1 in respiratory distress with O2 sats of 50% on room air. The resident's heart rate was 150 (normal 70 to 100) with abnormal rhythm. Cardioversion (use of electricity or medications to restore normal rhythm) was attempted three times without success and the resident's heart rhythm remained in [CONDITION(S)] flutter (an abnormal heart rhythm which may cause heart palpitations and shortness of breath). On 5/5/22 at 9:40 AM Witness 2 stated Resident 1 called him (on 12/5/21) at about 6:30 AM because she/he needed help but staff were not responding to the call light. Witness 1 called the facility and asked them to have staff respond to the resident. At about 7:00 AM the resident called Witness 2 again and told him she/he asked Staff 3 to call 911 but Staff 3 refused. Witness 2 stated she/he called 911 for the resident. Witness 2 stated when she/he arrived at the hospital the resident was unconscious and the physician stated the resident's O2 sats were 50%. On 5/9/22 at 9:12 AM Staff 3 stated on 12/5/21 Resident 1 was agitated and was demanding to go to the hospital because she couldn't breathe. Staff 3 stated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 3 stated the resident was a frequent flier (a derogatory term used to indicate the resident was often transferred between the facility and the hospital) and would either call 911 her/himself or have Witness 2 call 911 for her/him. Staff 3 stated she did not check the resident's vital signs other than O2 sats which she stated was 95%. Staff 3 did not recall performing any other assessments of the resident at that time. Staff 3 stated she called for non-emergent transport to take the resident to the hospital. On 5/4/22 at 2:31 PM Staff 1 (Administrator) stated Resident 1 frequently went to the hospital. Staff 1 was asked, if an alert and oriented resident requested 911 be called to take them to the hospital then what should staff do? Staff 1 stated staff should call 911. Staff 1 was asked if there would ever be a reason to deny calling 911 at the request of an alert and oriented resident? Staff 1 replied no. Staff 1 confirmed Resident 1 was admitted the hospital on 12/5/21.

Based on interview and record review it was determined the facility failed to ensure staff adhered to professional standards of care for 1 of 3 sampled residents (#1) reviewed for change in condition. This failure resulted in delayed activation of the emergency medical system while the resident suffered from difficulty breathing. Findings include: Resident 1 was readmitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress Note dated 12/5/21 by Staff 3 (RN) indicated Resident 1 complained of shortness of breath and requested to be sent to the hospital. (The note did not include a thorough assessment by Staff 3 of the resident's condition related to difficulty breathing such as assessing lung sounds, heart sounds or rhythm, breathing rate or heart rate.) The resident had Witness 2 (Power of Attorney) call 911 for her/him and the resident was transferred to the hospital. (The note did not explain why Witness 2 called 911 instead of Staff 3.) The note indicated the Emergency Medical Technicians had a community nurse who could provide the resident education regarding appropriate uses and times for calling 911. (The note did not explain why the resident would benefit from such education.) A Hospitalist Progress Note dated 12/6/21 indicated Resident 1 was diagnosed at the hospital with acute respiratory failure including [CONDITION(S)] (the lack of enough oxygen in body tissues to sustain body functions) and hypercapnia (too much carbon [MEDICATION(S)] in the bloodstream typically caused by inadequate respiration). The resident was placed on a ventilator (mechanical breathing machine) attached to the resident's [CONDITION(S)]. The resident had wheezing coarse breath sounds. A hospital Discharge Summary dated 12/10/21 indicated EMS arrived at the facility and found Resident 1 in respiratory distress with O2 sats of 50% on room air. The resident's heart rate was 150 (normal 70 to 100) with abnormal rhythm. Cardioversion (use of electricity or medications to restore normal rhythm) was attempted three times without success and the resident's heart rhythm remained in [CONDITION(S)] flutter (an abnormal heart rhythm which may cause heart palpitations and shortness of breath). On 5/5/22 at 9:40 AM Witness 2 stated Resident 1 called him (on 12/5/21) at about 6:30 AM because she/he needed help but staff were not responding to the call light. Witness 1 called the facility and asked them to have staff respond to the resident. At about 7:00 AM the resident called Witness 2 again and told him she/he asked Staff 3 to call 911 but Staff 3 refused. Witness 2 stated she/he called 911 for the resident. Witness 2 stated when she/he arrived at the hospital the resident was unconscious and the physician stated the resident's O2 sats were 50%. On 5/9/22 at 9:12 AM Staff 3 stated on 12/5/21 Resident 1 was agitated and was demanding to go to the hospital because she couldn't breathe. Staff 3 stated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff 3stated the resident was a frequent flier (a derogatory term used to indicate the resident was often transferred between the facility and the hospital) and would either call 911 her/himself or have Witness 2 call 911 for her/him. Staff 3 stated she did not check the resident's vital signs other than O2 sats which she stated was 95%. Staff 3 did not recall performing any other assessments of the resident at that time. Staff 3 stated she called for non-emergent transport to take the resident to the hospital. On 5/4/22 at 2:31 PM Staff 1 (Administrator) stated Resident 1 frequently went to the hospital. Staff 1 was asked, if an alert and oriented resident requested 911 be called to take them to the hospital then what should staff do? Staff 1 stated staff should call 911. Staff 1 was asked if there would ever be a reason to deny calling 911 at the request of an alert and oriented resident? Staff 1 replied no. Staff 1 confirmed Resident 1 was admitted the hospital on 12/5/21.

Based on interview and record review it was determined the facility failed to provide care and services to prevent a [CONDITION(S)] for 1 of 3 sampled residents (#3) reviewed for urinary catheter care. This failure resulted in Resident 3 being transferred to the hospital due to a [CONDITION(S)] with [CONDITION(S)] (a potentially life-threatening condition related to an infection). Findings include: Resident 3 was admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 3's Care Plan included an intervention for staff to monitor, record and report to the physician signs and symptoms of a [CONDITION(S)] including cloudiness, no output and altered mental status. Progress Notes from 12/23/21 through 2/12/22 revealed no assessment of Resident 3's urinary catheter, the quality of urine drainage or amount of output from the catheter. Progress Notes dated 2/13/22 revealed Resident 1 was less alert and more confused, sweating, muscle spasms and calling out for her/his mother because she/he thought she/he was falling. The resident was sent to the hospital for further evaluation. A hospital Discharge Summary dated 2/17/22 revealed Resident 3 was discharged from the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had severe [CONDITION(S)] due to a [CONDITION(S)] as a result of an obstructed Foley catheter. The resident's urine was packed with bacteria. The resident was treated with IV antibiotics. On 5/3/22 at 10:10 AM Witness 3 (Hospital RN) stated when Resident 3 arrived at the hospital on 2/13/22 the resident's urinary catheter was clogged with thick green foul smelling urine and it was the worst urine she/he had ever seen. The catheter tubing was unclean and crusted over where the tube entered the residents urethra (the tube where urine exits the body). The catheter tubing seemed old because it was not as flexible as it should have been. The catheter tubing around the urethra had to be soaked to loosen the crusty deposits before removing the catheter from the urethra to prevent tissue damage. Witness 3 stated she/he collected a urine sample for the lab and the lab told her/him it was the worst urine sample they had ever seen. On 5/11/22 at 12:59 PM the findings were presented to Staff 1 (Administrator) and she was asked to provide any additional information or documentation as soon as possible. No additional information or documentation was provided.

Based on observation, interview and record review it was determined the facility failed to ensure residents were free from abuse for 5 of 6 sampled residents (#s 1, 2, 3, 4 and 5) reviewed for allegations of abuse. This failure resulted in Residents 2 and 5 experiencing psychosocial harm including ongoing anger, fear, sleeplessness and increased isolation. Findings include: Resident 1 admitted to the facility in 2019 with [DIAGNOSES REDACTED]. Resident 1 discharged from the facility on 3/13/20. Resident 1's care plan for behaviors, initiated on 12/3/19, indicated staff monitored the resident's behaviors which included: cursing and yelling at staff, yelling and cursing at residents, physical aggression towards staff or residents, and appearing intoxicated after returning from the community. Interventions included assisting to a quiet area, redirection, offering snacks, allowing the resident to voice concerns, providing music and assisting to the toilet. On 1/10/20 a behavioral intervention was added to Resident 1's care plan which indicated the resident would have a one on one staff member with her/him at all times. Progress Notes from 1/2020 through 2/2020 indicated the one on one staff member began to be phased out beginning on 1/23/20 and was discontinued completely on 1/29/20. The one on one staff member intervention was reinstated on 2/14/20 and continued until the resident's discharge on 3/13/20. Behavior logs from 12/2019 through 3/2020 revealed Resident 1's behaviors increased in frequency over time. The behavior logs indicated each of the following behaviors occurred every day from 1/16/20 through 3/13/20: biting, grabbing, kicking/hitting, pinching/scratching/spitting, pushing, sexually inappropriate, threatening and yelling/screaming. Observations of Resident 1 in the facility dining room on 3/12/20 at 11:55 AM, 12:13 PM and 12:39 PM revealed the resident was talking loudly, yelling at staff members and residents, and belligerently antagonizing staff and residents with her/his words despite the presence of a one on one staff member. Staff were observed to attempt to redirect the resident, provide boundaries and encourage appropriate behaviors but the interventions were not effective. Staff were observed to encourage residents to leave the dining area to remove themselves from Resident 1's behaviors. Staff assisted residents to leave the dining area and the residents commented to staff members that they were unhappy with Resident 1's behaviors. Resident 1's antagonisms were so loud that her/his words were clearly audible from approximately five resident rooms away on both resident hallways adjacent to the dining room. On 3/12/20 at 11:55 AM Resident 1 declined to be interviewed as part of this investigation. Interviews were completed from 3/12/20 through 3/18/20 with the following staff and witnesses: Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (RNCM), Staff 4 (Maintenance), Staff 5 (CNA), Staff 6 (LPN), Staff 7 (Social Services), Witness 1 (State Survey Agency Policy Analyst) and Witness 2 (Former Resident Care Manager). The staff and witnesses indicated there were ongoing challenges with Resident 1's behaviors; and interventions related to managing Resident 1's behaviors were at times ineffective and became increasingly ineffective as the resident's behaviors increased in intensity and frequency. On 3/18/20 at 2:27 PM Staff 1 acknowledged the need for a facility review of Resident 1's admission process to determine if there was appropriate screening for behavioral concerns. Staff 1 indicated followup with community providers was needed in order to enhance the facility's ability to protect residents from abusive behaviors. 1. Resident 5 admitted to the facility in 1/2020 with [DIAGNOSES REDACTED]. A 2/21/20 incident report indicated Resident 1 was yelling and screaming and staff members when Resident 5 approached Resident 1 and told Resident 1 to not speak to staff in that manner. The residents then began yelling at each other. Staff asked Resident 5 to return to her/his room and the resident complied, but Resident 1 continued to yell at Resident 5. Witnesses reported Resident 1 yelled a variety of racial slurs and other derogatory comments about Resident 5's appearance and race. Resident 1 continued to engage in inappropriate behavior including disrobing and then ambulating around the facility while flying a remote control drone in resident areas despite staff attempts to intervene. Staff members eventually called the police. The police responded to the facility but did not make any arrests. Resident 5 was placed on psychosocial monitoring and was referred for mental health treatment subsequent to the incident on 2/21/20. Progress notes from 2/21/20 through 3/4/20 indicated Resident 5 experienced psychosocial decline as a result of the incident on 2/21/20. The notes indicate the following: - On 2/21/20 Resident 5 was distraught. - On 2/23/20 Resident 5 was tearful, expressed mental anguish, felt uneasy and felt hopeless regarding the 2/21/20 incident. - On 2/24/20 Resident 5 was anxious and stated the last few days were difficult and the resident felt overwhelmed. - On 2/25/20 Resident 5 displayed symptoms of depression including sadness, anxiety, fatigue, poor appetite, isolation and loss of interest in conversation and activities. Resident 5 attributed the symptoms to Resident 1's presence, racial slurs and demeaning comments. - On 2/27/20 Resident 5 was noted to have elevated blood pressure over the last few days. - On 2/29/20 Resident 5 presented with Stage 2 hypertension (elevated blood pressure with reading in excess of 140 over 90). The resident attributed the condition to stress. - On 3/2/20 Resident 5 was noted to have higher than usual baseline blood pressure. - On 3/4/20 Resident 5 expressed anxiety and was fixated on Resident 1's disruptive behaviors. Resident 5's care plan was updated on 2/22/20 to monitor for symptoms of increased depression. A review of Resident 5's medical record revealed Resident 5 received antidepressant medication daily prior to 2/21/20 and continued to receive the same medication and dosage. No evidence was found to indicate the resident required additional medication after the incident on 2/21/20. On 3/12/20 at 1:48 PM Resident 5 stated she/he was the victim of hate crimes perpetrated by Resident 1. Resident 5 stated Resident 1 manipulated, threatened and prevented residents from having any peace due to her/his loud and obnoxious behaviors. Resident 5 stated she/he witnessed Resident 1 sexually harass staff members and the resident did not have consequences for her/his behavior. Resident 5 stated the facility was supposed to have a zero tolerance policy for abusive behaviors, but Resident 1 violated the rules and got away with it. Resident 5 stated Resident 1 made racist and sexual comments towards her/him as well as towards staff members. Resident 5 stated she/he did not sleep very much because of Resident 1's loud behaviors and threats of physical violence towards her/him. Resident 5 stated Resident 1's behaviors caused her/him to have higher blood pressure. Interviews were completed from 3/12/20 through 3/18/20 with the following staff and witnesses: Staff 1 (Administrator), Staff 2 (DNS), Staff 5 (CNA), Staff 6 (LPN), and Witness 2 (Former Resident Care Manager). The staff acknowledged Resident 5 was a target of Resident 1's behaviors which included racist language and derogatory statements about Resident 5's appearance. On 3/13/20 at 2:34 PM Staff 5 stated Resident 5 spent more time in her/his room because of Resident 1's behaviors. On 3/13/20 at 3:02 PM Staff 6 stated Resident 5 appeared depressed, isolated and was just not (her/himself). Staff 6 stated Resident 5 needed one or two days to get back to baseline behaviors after the incident with Resident 1. On 3/17/20 at 12:09 PM Witness 2 stated Resident 1's behaviors really affected Resident 5. Witness 2 stated Resident 5 became more anxious, had a hard time sleeping at night and expressed fear of Resident 1 due to Resident 1's behaviors. On 3/18/20 at 2:02 PM Staff 2 stated Resident 5 stopped coming to activities when Resident 1 was present. Staff 2 stated after Resident 1 discharged from the facility Resident 5 was in a better mood and socialized more with other residents. Despite the facility's interventions related to Resident 1's abusive behaviors, Resident 1 continued to engage in abusive behaviors toward other residents including Resident 5. On 2/21/20 Resident 1 verbally abused Resident 5 which caused Resident 1 to experience psychosocial harm including fear, sleeplessness and isolation. 2. Resident 2 readmitted to the facility in 12/2019 with [DIAGNOSES REDACTED]. A 1/22/20 incident report indicated Resident 1 was outside in the smoking area and was screaming and making derogatory comments about other residents. Resident 1 went inside and continued screaming about other residents including Resident 2. Resident 2 was in her/his room with Witness 3 (Resident 2's spouse) when Resident 1 made the comments. Resident 1 accused Resident 2 of being a drug dealer and accused Witness 3 of injecting Resident 2 with illicit substances. Resident 2 heard the comments and confronted Resident 1. Staff intervened and separated the residents. Witnesses reported Resident 1 appeared intoxicated and was blocking other residents' exit paths with her/his wheelchair to prevent them from leaving the area. Grievances written by Resident 2, dated from 1/14/20 through 3/12/20, which included 43 pages of hand-written notes, documented Resident 1's behaviors towards Resident 2 and other residents. The grievances indicated Resident 1 verbally abused Resident 2 and other residents by yelling, threatening, harassing, antagonizing and demeaning the residents. The grievances indicated Resident 2 was about to have a mental breakdown and was unable to heal due to Resident 1's behaviors, which messed up my soul and asked, How long do we the residents of this facility have to keep putting up with this? A review of Resident 2's clinical record revealed the resident did not require medication or treatment changes as a result of her/his psychosocial state. Resident 2's care plan, revised on 2/3/20, included an intervention to discuss concerns with staff instead of confronting other residents. On 3/12/20 at 12:21 PM Resident 2 stated Resident 1 bothered her/him by threatening her/him, yelling and screaming, and calling the resident derogatory names like, big, fat (expletive) and making comments such as, You're gonna die in here. Resident 2 stated she/he wrote grievances about Resident 1's behavior. Resident 2 stated she/he avoided going to functions where Resident 1 was and sometimes stayed in her/his room because of Resident 1. Resident 2 stated the behaviors occurred on a daily basis. Resident 2 stated she/he was unable to get rest and heal because of Resident 1's behaviors. Resident 2 stated she/he woke up each day thinking about Resident 1's behaviors and every time she/he went into the hallway she/he worried about Resident 1. Resident 2 stated she/he felt she/he was about to have a nervous breakdown. During the interview Resident 2 demonstrated signs of sadness as the resident frowned and looked down at the floor. Attempts to contact Witness 3 (Resident 2's spouse) from 3/27/20 through 3/30/20 were unsuccessful. Interviews were completed from 3/12/20 through 3/18/20 with the following staff and witnesses: Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (RNCM), Staff 4 (Maintenance), Staff 5 (CNA), Staff 6 (LPN), Staff 7 (Social Services), and Witness 2 (Former Resident Care Manager). The staff and witnesses acknowledged Resident 2 was a target of Resident 1's behaviors. On 3/13/20 at 1:58 PM Staff 2 indicated Resident 2 was offered mental health counseling but the resident refused. Staff 2 stated Resident 2 was still angry about Resident 1's behaviors. On 3/13/20 at 2:34 PM Staff 5 stated since the incident on 1/22/20 any time Resident 2 saw or heard Resident 1, Resident 2 said her/his rights were being violated. Staff 5 stated Resident 2 spent more time in her/his room than she/he did prior to the 1/22/20 incident. Staff 5 stated Resident 2 previously ate meals in the dining room but currently ate all meals in her/his room and did not socialize as often as she/he previously did. On 3/17/20 at 12:09 PM Witness 2 stated Resident 2 verbalized a lot of frustrations and Resident 1 was the sole focus of Resident 2's frustrations. Despite the facility's interventions related to Resident 1's abusive behaviors, Resident 1 continued to engage in abusive behaviors toward other residents including Resident 2. On 1/22/20 Resident 1 verbally abused Resident 2 which caused Resident 1 to experience psychosocial harm including prolonged anger and increased isolation. 3. Resident 4 admitted to the facility in 11/2019 with [DIAGNOSES REDACTED]. A police report and facility incident report, both dated 2/14/20, indicated Resident 1 was outside in the smoking area with Resident 4 and other residents. Resident 1 called Resident 4 derogatory names including pedophile and drug dealer and flew a remote controlled drone aircraft near the other residents' faces. Resident 4 approached Resident 1 and confronted her/him about the resident's behaviors and a physical altercation ensued. Staff separated the residents and no injuries were determined. Witness reports indicated Resident 1 called Resident 4 derogatory names and threatened the resident. After the incident, Resident 1 told staff, (Expletive) you, I can do (expletive) I want. It was noted that Resident 1 instigated the incident with Resident 4. A review of Resident 4's clinical record revealed the resident was monitored following the incident on 2/14/20, but no evidence was found to indicate the resident experienced psychosocial decline. On 3/12/20 at 1:03 PM Resident 4 stated Resident 1 screamed, yelled, threatened and called her/him names. Resident 4 stated she/he was not injured during the 2/14/20 incident. Resident 4 stated she/he was still able to have a life but avoided Resident 1 as much as possible. Interviews were completed from 3/12/20 through 3/18/20 with the following staff and witnesses: Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (RNCM), Staff 4 (Maintenance), Staff 5 (CNA), Staff 6 (LPN), Staff 7 (Social Services), and Witness 2 (Former Resident Care Manager). The staff and witnesses acknowledged Resident 4 was a target of Resident 1's behaviors. The staff and witnesses indicated Resident 4 was monitored after the 2/14/20 incident and did not exhibit any indication of psychosocial decline as a result of the 2/14/20 incident. 4. Resident 3 admitted to the facility in 2019 with [DIAGNOSES REDACTED]. A 1/10/20 incident report indicated Resident 3 was in the smoking area with Resident 1 and the two residents began arguing. Resident 3 tried to leave the area but Resident 1 blocked the exit. Witnesses reported Resident 1 used her/his hands to strike Resident 3 multiple times in the face and Resident 3 did not strike Resident 1. A staff member separated the residents. Resident 3 sustained minor injuries to her/his face. The police responded but did not arrest Resident 1 as Resident 3 did not want to pursue criminal charges. No evidence was found to indicate prior or subsequent conflicts between Residents 1 and 3. A review of Resident 3's clinical record revealed no prior concerns with resident to resident incidents or aggression. Progress notes from 1/10/20 through 1/17/20 revealed Resident 3 was monitored for signs of psychosocial decline after the 1/10/20 incident but no concerns were noted. The progress notes indicated Resident 3 refused treatment for [REDACTED]. No evidence was found in Resident 3's clinical record to indicate the resident required treatment or medication related to her/his minor injuries sustained in the 1/10/20 incident. On 3/12/20 at 12:52 PM Resident 3 stated the incident on 1/10/20 occurred when Resident 3 tried to talk to Resident 1 about negative things Resident 1 said about other residents. Resident 3 stated Resident 1 started hitting her/him and then staff responded and separated the residents. Resident 3 estimated she/he was hit about ten times. Resident 3 stated she/he sustained minor facial injuries that lasted about one week and did not have much pain. Resident 3 stated she/he declined to press charges and did not have any further problems with Resident 1. Interviews were completed from 3/12/20 through 3/18/20 with the following staff and witnesses: Staff 1 (Administrator), Staff 2 (DNS), Staff 3 (RNCM), Staff 4 (Maintenance), Staff 5 (CNA), Staff 6 (LPN), Staff 7 (Social Services) and Witness 2 (Former Resident Care Manager). The staff and witnessed acknowledged Resident 1's behaviors and indicated Resident 1 instigated the incident on 1/10/20. None of the staff or witnesses indicated additional incidents occurred between Resident 1 and Resident 3. The staff and witness indicated Resident 3 was monitored after the 1/10/20 incident and did not exhibit any indication of psychosocial decline as a result of the 1/10/20 incident.

Based on interview and record review it was determined facility staff failed to ensure professional standards were followed regarding thoroughly assessing [MEDICAL CONDITION], changes in condition and surgical wound; initiate alert charting related to changes in condition, ensuring the physician was fully informed of the resident's status and intervening timely when the resident experienced changes in condition for 2 of 4 sampled residents (#s 1 & 4) reviewed for changes in condition. Staff 3, RNCM, Staff 7, RN, Staff 8, RN, Staff 11, RN & Staff 25, RN failed to thoroughly assess Resident 1's [MEDICAL CONDITION], changes in condition, initiate alert charting, ensure the physician was fully informed of the resident's status and intervene timely when Resident 1 experienced a change in condition. Staff 5, RN, failed to thoroughly assess Resident 1's [MEDICAL CONDITION]. Staff 4, RNCM, Staff 8, RN & Staff 11, RN failed to thoroughly assess Resident 4's surgical wound. Resident 1 did not receive medical attention in a timely manner, was hospitalized and required emergent treatment. Resident 4 was at risk of complications from a surgical wound. Findings include: "Division 45 Standards and Scope of Practice For The Licensed Practical Nurse and Registered Nurse 851-045-0040 Scope of Practice Standards for All Licensed Nurses (1) Standards related to the licensed nurse's responsibilities for client advocacy. The licensed nurse: (b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering; 851-045-0060 Scope of Practice Standards for Registered Nurses (2) Standards related to the Registered Nurse's responsibility for nursing practice implementation. Applying nursing knowledge, critical thinking and clinical judgment effectively in the synthesis of biological, psychological, social, sexual, economic, cultural and spiritual aspects of the client ' s condition or needs, the Registered Nurse shall: (a) Conduct and document initial and ongoing comprehensive and focused nursing assessments of the health status of clients by: (D) Anticipating and recognizing changes or potential changes in client status; Identifying signs and symptoms of deviation from current health status..." 1. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 12/27/13 Admission Nursing Database assessed Resident 1 as alert and oriented to person, place and time. The resident had a Foley catheter in place and [MEDICAL CONDITION] (swelling) to the scrotum, redness in color. At the time of the survey, there was no documented assessment of the resident's scrotal [MEDICAL CONDITION], including the extension and degree/measurement of the [MEDICAL CONDITION], completed at the time of admission. The 12/26/13 Admission Physician order [REDACTED]. The 12/27/13 Admission Initial Pain Questionnaire noted Resident 1 did not have pain at the time of the assessment. The 12/31/13 and 1/1/14 Progress Notes indicated scrotal [MEDICAL CONDITION] was noted, with no documented assessments of the [MEDICAL CONDITION]. The 1/2/14 CAA for pain noted the resident reported back and flank pain. The resident stated Tylenol was not working to take away the pain but he did not need any narcotics. "If resident has an increase in pain, the proper medication will be initiated." On 1/3/14 the physician ordered ice packs to the scrotum for 15 minutes, four times a day and as needed for pain/swelling. Per the 1/2014 TAR the ice packs were administered as ordered. According to the 1/2014 TAR, on 1/6/14 the Weekly Skin Check was documented as a "+." At the time of the survey, there was no documented assessment of the identified skin impairment. The 1/8/14 Physician History and Physical noted the resident had resolving scrotal [MEDICAL CONDITION], which was described as "mild" with no [DIAGNOSES REDACTED] (redness). No drainage was noted. The 1/8/14 Occupational Therapy Treatment Encounter Note indicated the resident reported the physician had just been in and "there was lots of drainage from cath site." Staff 26, Rehab Director/Occupational Therapist, "recommended change in brief as there was significant drainage from catheter site." On 1/9/14 the physician ordered [MEDICATION NAME] (a diuretic) 2 mg daily. According to the 1/2014 MAR, the [MEDICATION NAME] was given as ordered. Resident 1 did not receive the PRN Tylenol from 1/2/14 through 1/9/14. The 1/10/14 Occupational Therapy Treatment Encounter Note indicated the resident was able to stay up in the wheelchair for 30 minutes before being assisted back to bed. The 1/10/14 2:59 am and 1/11/14 2:27 am Progress Notes revealed Resident 1 complained of 6 out of 10 pain in the "prostate area" with Tylenol given. The 1/11/14 4:41 pm Progress Note disclosed Resident 1 had 8 out of 10 back pain, which decreased to 7 out of 10 after he was given Tylenol. An "increase" in pus was noted at the catheter insertion through the urinary tract. The resident complained of severe burning and pain as if "traveling up the catheter." The pus and urine was described as malodorous (foul smelling). On 1/11/14 the physician ordered a urinalysis with culture and susceptibility be obtained and ordered medications including [MEDICATION NAME] (an antibiotic) for a UTI (urinary tract infection) for seven days and [MEDICATION NAME] 5/325 one tablet every six hours as needed for pain. The 1/12/14 2:27 am and 1/13/14 4:16 am Progress Notes indicated the resident had 6 out of 10 pain in the prostate area. The 1/13/14 3:24 pm and 1/14/14 3:21 pm Progress Note disclosed a small amount of pus was still noticeable at the tip of the penis. The resident denied pain in the urinary tract. On 1/14/14 the physician discontinued the [MEDICATION NAME] and ordered Bactrim for seven days. Per Staff 2's, DNS, summary of the resident's stay, the physician changed the antibiotic based on susceptibility for treating the UTI. The 1/2014 MAR noted on 1/16/14 at 5:00 am, Resident 1 was administered [MEDICATION NAME] for reported pain of 5 out of 10. The 1/16/14 Occupational Therapy Treatment Encounter Note, signed at 11:03 am, indicated "upon self propelling w/c (wheelchair) down to therapy gym, pt (patient) stated 'I need to go to the ER.' OT notified nursing, RCM came down to have discussion with pt regarding request. Nursing recommended pt. return to bed so she could assess situation." Resident 1 had 6 out of 10 scrotal pain and was up in the wheelchair approximately "20 min prior to having to return back to bed." The 1/16/14 2:39 pm Progress note revealed at 9:00 am, "observed scant bloody, purulent (containing pus) foul smelling discharge from penis, catheter care performed, unable to expose meatus..." (opening at the tip of the penis) due to tightening of the foreskin. The 1/16/14 Physical Therapy Treatment Encounter Note, signed at 2:22 pm, indicated during transfers "Pt unable to get more than 2 inch of clearance off bed. Trials 2x's." The resident became very painful in the scrotal area, reporting 8 out of 10 pain and needed to lay back down. After lying on his back and applying ice the resident reported a pain level of "3 1/2." It noted the resident's pain limited his functional activities. "Due to increased pain patient very resistant to moving around too much which irritates scrotal area....Time spent talking with charge nurse about patients status. Pt still very painful from this morning. At first pt unwilling to trial standing but with reassurance from therapist pt willing to trial if it didn't cause to (sic) much more pain." Staff 28, Physical Therapist, documented pain as a barrier during the session. On 1/16/14 the physician referred Resident 1 to a urologist for scrotal/meatal [MEDICAL CONDITION]. At the time of the survey, there was no documented thorough assessment of the resident's status, including the extension, degree and measurement of the scrotal [MEDICAL CONDITION], the skin integrity of the penis when the resident was noted to have a change in condition to the scrotal area and the impact pain was having on therapy. There was no documented evidence alert charting had been initiated, nor was there documented follow up of the resident's request to be sent to the emergency room . The 1/2014 MAR noted on 1/16/14 at 9:40 pm, Resident 1 received [MEDICATION NAME] for reported pain of 7 out of 10 and on 1/17/14 at 10:00 am for a pain level of 6 out of 10. Staff 28, Physical Therapist, documented on the 1/17/14 Physical Therapy Treatment Encounter Note "Spoke with RCM about patients pain in groin area. Pt fearful of causing more pain with bed mobility and transfers. Held transfer/bed mobility training today..." The 1/18/14 1:47 am Progress Note revealed Resident 1 complained of 6 out of 10 pain, "given prn [MEDICATION NAME]" There was no correlating documentation regarding the administration of the [MEDICATION NAME] on either the 1/2014 MAR or the Narcotic Record. 1/18/14 and 1/19/14 Progress Notes indicated physical and occupational therapies were not scheduled for Resident 1 on those days. The 1/19/14 1:09 am Progress Note indicated Resident 1 complained of 9 out of 10 pain, which was treated with [MEDICATION NAME]. The 1/20/14 2:26 am Progress Note revealed the resident had "scant" amount of blood noted in the brief and around the meatus. Resident 1's Narcotic Record noted the resident received [MEDICATION NAME] on 1/20/14 at 10:30 am. There was no further documentation on the MAR or the Progress Notes regarding the administration of the medication nor the resident's pain level. The 1/20/14 12:41 pm Progress Note revealed paramedics arrived at 11:30 am after receiving a call from a friend of Resident 1. The resident agreed to go with the paramedics, "no MD orders received, AMA (against medical advice) paperwork signed." At the time of the survey, there was no documented assessment of Resident 1's scrotal [MEDICAL CONDITION], including the condition of his penis when the resident left with paramedics on 1/20/14. At the time of the survey, the resident had not returned to the facility. The 1/20/14 Emergency Department Encounter Note, signed by Witness 4, Physician on 1/24/14, indicated Resident 1 presented to the Emergency Department with pus like drainage from around the penis with a necrotic appearing penis, which was described as "grayish black." "He is a diabetic and clearly is at risk for serious soft tissue infections including [DIAGNOSES REDACTED] (a bacterial infection). After my initial evaluation of the patient [MEDICAL CONDITION] protocol was promptly initiated...Antibiotics were promptly ordered that [MEDICAL CONDITION] doses...I immediately put a call out to general surgery...because of my concern for necrotizing fascitis/fourniers (a type of gangrene that involves the genital organs)." Per the report, one of the surgeons contacted requested a CT scan. "I expedited that CT by having the charge nurse call CT to let her know we needed to get this study emergently and I spoke to the CT technician as well to express my need for an emergent scan. Meanwhile, we continued treatment for [REDACTED]. nauseated and then promptly became unresponsive...chest compressions were initiated....After 2 minutes of chest compressions a weak pulse was felt centrally." It was decided "to further stabilize him in the intensive care unit prior to going to the operating room. The patient was admitted to the ICU in extremely critical condition." The 1/25/14 Discharge Summary noted a pathology report from 1/20/14 revealed "Penile tissue showing extensive necrosis and acute inflammation consistent with necrotizing fascitis." Procedures included a total penectomy (surgical removal of the penis). The resident was discharged to a local hospital burn center for further treatment. In interview on 3/14/14 at 10:35 am, Witness 1, Complainant, stated Resident 1 did not normally complain of pain, but was reporting a lot of it and when he reported it, he was in significant pain. The resident could only sit in his wheelchair for a couple of minutes. The resident asked to be sent to the emergency roiagnom on at least two occasions. Witness 1 stated on 1/16/14, she had cleaned the resident up herself when Resident 1 had bleeding and foul smelling pus. Witness 1 stated she informed Staff 7, RN, that Resident 1's brief was all full of blood and smelled really bad. When asked if Staff 7 assessed the resident at that time, Witness 1 stated "no." In interview on 3/10/14 at 10:02 am, Resident 1 stated he was "pleading" with staff to get him to a physician for approximately 10 days. He stated he wanted to go to the ER, but staff turned him down on that request. Resident 1 reported he had tremendous amount of pain and wanted to go back to bed after therapy would transfer him to the wheelchair. Resident 1 stated he was clear at the time, but the closer he came to being taken out of the facility by ambulance, the foggier he became. Per Resident 1, Witness 6, Family, called paramedics for him. In interview on 3/14/14 at 11:00 am, Witness 6, Family, stated she had spoken with Resident 1 and Witness 1, Complainant, and Resident 1 was having a lot of bleeding and pus issues for approximately a week or so before going to the hospital. Witness 6 stated when she spoke on the phone with Resident 1 on 1/20/14, Resident 1 was short of breath and reported bleeding during his shower . Witness 6 stated she called 911 and reported the resident was losing blood and having breathing problems. In interview on 3/14/14 at 11:36 am, Staff 11, RN, stated he was not sure if the resident's scrotal [MEDICAL CONDITION] was assessed daily or weekly. The weekly assessments were documented on the TAR. CNA staff observed the area every day and if anything was abnormal they would report it to the nurse so it could be assessed. Staff 11 stated CNA staff reported changes to the resident on 1/16/14. When Staff 11 observed the resident's scrotal [MEDICAL CONDITION] and penis on 1/16/14, he "did not know what to make of it." Staff 11 stated the penis had a "dusky color", which he stated he forgot to document, the foreskin was really tight, he could not expose the meatus and he had never seen anything like that before. Staff 11 stated he had Staff 3, RNCM, observe the area and Staff 3 arranged for a urology appointment for the resident. Staff 11 stated it was "definitely a change" for the resident, which he described as "unusual." Staff 11 stated the resident complained of pain more often just prior to going to the hospital. When asked if Resident 1 had requested to see a physician or go to the hospital, Staff 11 stated "not directly." Per Staff 11, Resident 1 stated something seemed wrong and something should be done about it. In interviews on 3/14/14 at 12:24 pm and 3/24/14 at 10:00 am, Staff 7, RN, stated the resident was not good about reporting pain, and would report pain when it was out of control or she would learn of it second hand from family. Staff 7 stated she participated in Resident 1's admission intake in 12/2013. Staff 7 stated initially the resident had [MEDICAL CONDITION] from the testicles into the penis. Staff 7 stated when she documented the "+" on the 1/6/14 skin check, she did not initiate a Skin Grid for further documentation as her finding was related to the resident's penis, which staff were already monitoring. Staff 7 stated there was more discharge and there was increased swelling to the tip of the penis. The discharge did not have the odor that occurred later. Per Staff 7, later there were concerns the foreskin was no longer able to be retracted and there was discoloration at the tip of the penis. Staff 7 stated the penis tissue was changing in color, the tip turned white, which was non-blanchable, which started with small white patches that became larger, nothing that anyone had ever seen before. Staff 7 stated she discussed her concerns of the discoloration, not being able to retract the foreskin, and possible infection and strangulation of the penis, which were not going away and was becoming more painful for the resident, with Staff 2, DNS and Staff 3, RNCM on at least two occasions. Staff 7 stated she had those discussions with Staff 2 and 3 both the week prior and a few days prior to the resident being sent out to the hospital. Staff 7 stated she did not call the physician herself about the resident's status as it was protocol to inform Staff 2 or Staff 3 for follow up. Staff 7 stated there was a statement from the resident about wanting to see a physician. The resident had an appointment with a urologist and she thought the facility was also working on the resident being seen by the facility physician. Per Staff 7, on 1/19/14 she told Staff 3 there was a change in discharge odor and the area was more reddened. In interview on 3/14/14 at 12:47 pm, Staff 12, CNA, stated while providing catheter care, he observed the resident's scrotal area/penis was very swollen. On 1/16/14 he was not able to clean the resident's foreskin. Staff 12 stated the discharge coming out of the resident's penis had an odor, which increased during the resident's stay in the facility. Staff 12 stated the resident asked to see the nurse, then the resident would ask the nurse about seeing the physician that came to the facility. Staff 12 was unable to recall when Resident 1 made those requests. In interview on 3/14/14 at 1:29 pm, Staff 8, RN, stated Resident 1 had some infection starting, which was not clearly identifiable, no one knew what was going on. The foreskin was swollen and the physical assessment was difficult to do because of the foreskin swelling. At one point she had Staff 3, RNCM, assess the resident's penis, which did not look normal. Staff 8 stated Resident 1's penis appeared to have a white area on the meatus, two spots that were the size of "the tip of a pencil." The next time Staff 8 visualized the area, the white spots were spreading and the entire tip of the penis was white. Staff 8 stated she could not see the insertion point of the catheter because the foreskin was swollen tight. Staff 8 stated when she visualized the changes, she had never seen anything like it before. Staff 8 stated the changes to the discoloration were over the course of a week to a week and a half, just before the resident went to the hospital. Staff 8 stated there was drainage from the urethra/penis, which occurred off and on. At one point the resident had some blood coming out of the catheter point while the resident was sitting on a toilet. Staff 8 stated she was not under the impression she had to update the Skin Grid every time she went in and visualized the penis/scrotal area and did not document her assessments. Staff 8 stated she did not contact the physician directly regarding the resident's status, but informed Staff 3. In interview on 3/14/14 at 2:26 pm, Staff 21, CNA, stated Resident 1's penis was very swollen and staff had to make sure they provided the catheter care because of the drainage. Staff 21 stated he checked on the resident's drainage twice an hour as he would try to control the odor and the smell of the resident's room. Staff 21 described the drainage as sometimes a little, sometimes a lot and at times blood was mixed with the drainage. Staff 21 stated the resident asked to go to the hospital or see a physician, which he reported to the nurse, but he could not recall when or how often the resident made the request. The resident's pain level depended on the day, sometimes it was okay, other times it was totally painful when he provided peri care for the resident. In interview on 3/17/14 at 1:35 pm, Staff 5, RN, stated she was off schedule for four days and upon her return learned the resident had left the facility AMA. Staff 5 stated on one occasion when she had assessed Resident 1's scrotal area, there was scant bleeding and the penis was really swollen, but it was hard to visualize because of the swelling. Staff 5 stated it was a known thing by the day nurse and Staff 3, RNCM. As the night nurse she checked it and passed the information along. In interviews on 3/24/14 at 10:08 am and 3/25/14 at 10:13 am, Staff 26, Rehab Director/Occupational Therapist, stated when Resident 1 was initially admitted to the facility, he had pain, but by 1/6/14 the pain was declining. On 1/10/14 the resident was able to tolerate sitting in the wheelchair for 30 minutes before going back to bed and he was doing a little better in functional skills. On 1/15/14 to 1/16/14 the resident started to decline again in functional skills due to a higher increase in scrotal pain. On 1/16/14 the resident reported he was painful prior to therapy but he was willing to try to get up in the wheelchair. He reported a pain level of 6 out of 10 in the scrotal area just from being up in the wheelchair for 20 minutes. On the way down to the therapy gym, the resident stated he thought he needed to go to the emergency room . Staff 26 stated she asked the resident a couple of times if he wanted to go to the hospital "right now", to which the resident responded "yes." Staff 26 stated she got Staff 3, RNCM, and all three of them went into the therapy gym. The resident expressed his concerns that he thought he needed another procedure to release pressure in the scrotal area. Staff 3 had the resident lie down in bed so she could assess the area. In interview on 3/24/14 at 2:47 pm, Staff 28, Physical Therapist, stated Resident 1 was "pretty painful" before he went to the hospital and they did certain things to accommodate the pain. Staff 28 stated the resident had pain at admission, he did better for about a week, then the pain started "ramping up again." The resident's groin was very swollen and painful. Staff 28 stated she spoke with Staff 3, RNCM, about the resident's pain, who stated they would check into it. In interviews on 3/17/14 at 11:33 am and 3/19/14 at 11:37 am, Staff 22, CNA, stated when Resident 1 was first admitted to the facility he was really quiet and did not voice any concerns regarding pain. Per Staff 22, the resident began reporting pain a week to a week and a half before going to the hospital. Staff 22 stated on the day before the hospitalization (1/19/14) and the day of the hospitalization (1/20/14), Resident 1 was having a lot of pain and he wanted to know what they were doing for him or if he should go to the hospital. Staff 22 stated the resident had bleeding before, during and after a shower on 1/20/14, which Staff 22 described as continuous, like a slow dripping faucet. Staff 22 stated she reported the bleeding to Staff 25, RN, several times that day. Staff 22 stated she placed a basin under the resident's shower chair to catch the bleeding. During the resident's shower, Staff 25, RN, came down to the shower room, looked at the resident's penis and the blood in the basin and left. Per Staff 22, Resident 1 was pretty upset about the bleeding and wanted to know what staff were doing to address it. Staff 22 stated the resident was normally pretty easy going but at this time he was getting more distraught. Staff 22 stated the resident's friend called, he told his friend he was having some problems and not feeling very good. The resident's friend offered to get him and take him to the hospital, but the resident said he could not leave AMA, and the friend called 911. In interviews on 3/24/14 at 11:36 am and 3/25/14 at 3:50 pm and 4:48 pm Staff 25 RN, stated when she documented about the "increased drainage" on 1/11/14, the scrotal area was very swollen and the meatus was "very strange", it was retracted a little bit but she could not recall any discoloration of the penis. Staff 25 stated later there was more drainage and the resident started bleeding, but she could not recall when the bleeding started. Staff 25 stated they knew things were progressively getting worse and she thought they were communicating with Staff 3, RNCM, and the physician. Staff 25 stated Staff 8, RN, had previously told her Staff 8 had observed some white spots on the resident's penis. However, Staff 25 stated it was hard to tell because the foreskin was so retracted. Staff 25 stated she reported to the physician it was hard to assess the area because she could not see what was going on. Staff 25 stated the resident's condition was really different, something she was not used to dealing with. Staff 25 stated on 1/20/14 a CNA told her the resident was bleeding, which the CNA showed her. The resident was having a "good amount of blood" loss from his penis, around the catheter, more than a normal amount and she notified the physician. The meatus was swollen and she could not remember if there was any discoloration to the penis. When asked about the documentation of her findings, Staff 25 stated charting was a little bit difficult as she charted whatever she could remember at the end of the shift. Staff 25 stated she spoke with Staff 3 about the resident's condition and Staff 3 did not want to send the resident out to the hospital. Staff 25 stated she did not think Staff 3 understood the severity of the resident's condition, "I don't think anyone realized it was that severe." Staff 25 stated they shared with the physician about the drainage, the pus and the bleeding, but before they could do anything about it the resident's friend called for an ambulance. In interview on 3/18/14 at 11:48 am and 3/25/14 at 10:20 am Staff 3, RNCM, stated she was not aware of the discoloration of the resident's penis as observed by nursing staff. At one point the resident did not participate in therapy because of pain or did minimal participation, but she could not recall when that occurred. Staff 26, Rehab Director/Occupational Therapist, asked about the resident's scrotal swelling, which she informed Staff 26 was chronic. Staff 3 stated at one point the resident requested to see the physician the next time he was in, but she could not recall when the resident made that request. Staff 3 stated prior to 1/16/14, she knew Resident 1 was being treated for [REDACTED]. Staff 3 stated Staff 11, RN, reported to her on 1/16/14 Resident 1 had increased drainage and swelling. Staff 3 stated she went to the resident's room with Staff 11 and assessed the resident's scrotal area/penis. The scrotum was very enlarged and she could not recall any discoloration of the penis. When asked about the resident's request to go to the emergency roiagnom on [DATE], Staff 3 stated she did not recall being informed of that request. The resident was having pain, she went to the therapy gym, had the resident lie down and she assessed the resident's scrotal area. Staff 3 stated she called the physician, who referred the resident to a urologist. Staff 3 stated she could not recall if she had reported the resident's pain, therapy participation and request to go to the emergency room to physician. On 1/20/14 she spoke with the resident about his concerns regarding getting an earlier appointment with the urologist. At that time, the resident had an increase in pain overall, the scrotal swelling had increased and there was quite a bit of drainage but she could not recall if there was any discoloration of the penis. Staff 3 stated she was not aware Resident 1 had bleeding on 1/20/14. The physician wanted to change treatment to a stronger antibiotic that day, however, the resident talked to his friend, who called 911. Due to having no orders for the resident to go to the hospital, she had the resident sign AMA paperwork. At the time of the survey, Staff 3 did not provide documentation of either the 1/16/14 or 1/20/14 assessments. In interview on 3/18/14 at 1:09 pm, Staff 2, DNS, stated she was not aware of the discoloration and white spots on Resident 1's penis observed by nursing staff. Staff 2 stated she expected the facility's policy regarding documentation and communication be followed, documenting and reporting everything, so the staff reporting to the physician would have a clear picture. Staff 2 stated they relied on the physician for when he wanted to see a resident. Staff 2 stated there were no orders to send the resident to the hospital on [DATE]. In interview on 3/25/14 at 4:05 pm, Witness 5, Physician, stated nursing staff reported there was an abnormality of the resident's penis, but could not recall if staff reported there were white spots that worsened on the tip of the penis and did not know what to make of the 1/16/14 nurse's observation of the penis appearing dusky. Witness 5 stated he did not recall being informed of the resident's request to go to the Emergency Department. Witness 5 stated he had been told the resident's pain was "minimal to intermittent" from 1/16/14 until the day he left the facility. Witness 5 stated had he "been given the information there was progressive or pronounced pain, would want to get that assessed." When the resident had pain on the morning of 1/20/14, the resident was informed Witness 5 would see him that day, but the resident did not want to wait. Witness 5 stated he could not state if he was informed about the resident's bleeding on 1/20/14, but if there was a lot of pain and a lot of bleeding the resident should have been sent to the hospital via emergency services. Witness 5 stated he remembered telling staff to send the resident out via emergency services because the resident was having too much pain and staff reported a friend wanted to take the resident out of the facility AMA (against medical advice). In interview on 3/13/14 at 9:00 pm, Witness 4, Emergency Department Physician, stated Resident 1's penis appeared "pretty necrotic" when he came into the Emergency Department. Witness 4 stated regarding necrotizing fascitis, "no matter where it is in the body is clearly time dependent for treatment, the sooner it is taken care of the better." 2. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/9/14 Admission Physician order [REDACTED]. The 1/10/14 Admission Nursing Database noted Resident 1 was admitted with a lumbar surgical incision scab 8.5 x 0.4 cm with scant serosanganeous drainage, that was sealed with [MEDICATION NAME] glue. The 1/10/14 Skin Grid For All "Other" Skin Problems was initiated for the surgical wound status at admission. At the time of the survey, there were no further documented assessments of the surgical wound. The 1/11/14 Physician order [REDACTED]. The 1/13/14 Physician order [REDACTED]. On 1/14/14 the physician was informed the bactricin ointment was not available. The physician changed to treatment to a triple antibiotic ointment. According to the 1/2014 MAR and TAR, with the exception of the unavailable antibiotic ointment, all other medications and treatments related to the surgical wound were done as ordered. The 1/17/14 2:43 am Progress Note revealed Resident 4's heart rate was in the 140's and she/he had a temperature of 103.8. The resident complained of chills and feeling "achy" and was sent to the hospital. The 1/17/14 Trauma Surgery Admission History and Physical and Consultation Reports noted Resident 4 had a midline lumbar incision, not completely healed with serosanguinous drainage. The wound was partially dehisced (re-opening of a surgical wound). The resident was found to have a postoperative lumbar wound infection. The 1/21/14 Admission Nursing Database noted Resident 1 was readmitted with a surgical incision to the mid-back, 15.5 x 0.1 cm with 29 staples. The 1/21/14 Skin Grid For All "Other Skin Problems was initiated for the surgical wound status at re-admission. Again, at the time of the survey, there were no further documented assessments of the surgical wound. The 2/20/14 2:10 am Progress Note disclosed Resident 4 discharged to home. In interview on 3/17/14 at 1:19 pm, Staff 6, LPN, stated Resident 4's wound had some drainage when she/he was first admi

Based on interview and record review it was determined the facility failed to thoroughly assess [MEDICAL CONDITION], changes in condition and surgical wound; complete alert charting related to changes in condition, ensure the physician was fully informed of the resident's status and intervene timely when the resident experienced changes in condition for 2 of 4 sampled residents (#s 1 & 4) reviewed for changes in condition. Resident 1 did not receive medical attention in a timely manner, was hospitalized and required emergent treatment. Resident 4 was at risk of complications from a surgical wound. Findings include: The facility's Policy and Procedure for Managing Acute Condition Change noted the following: "The facility will ensure that each resident maintains the highest practicable physical, mental and psychosocial well being by identifying and managing acute changes through the alert charting process. Alert charting will be initiated by the charge nurse or RCM for any change in the resident's condition that necessitates frequent observation and recording. Procedure for Alert Charting: 1. Assess the resident experiencing a change for whatever reason. 2. Notify the physician and family/responsible party without delay. 3. Document the current status of the resident in the nurses' notes. 4. Initiate alert charting for the resident by putting the resident's name on his/her specific MACC (Managing Acute Condition Change) log. 5. Follow the 'Alert Charting Recommendations' for what to include in the assessments, what to document, monitor and how often. 6. The MACC log will include the...alert rational, what is to be assessed and documented, the frequency of charting, what to monitor and check that the family and MD were notified.... Alert Charting Recommendations: Abnormal [MEDICAL CONDITION] Alert Charting Q (every) shift as condition warrants...Location and extension of [MEDICAL CONDITION], Degree/Measurement of [MEDICAL CONDITION] tolerance...Impaired circulation/skin integrity." The Facility's Policy and Procedure for Skin At Risk/Skin Breakdown noted the following: "1....Within 8 hours of admission, a Licensed Nurse will examine the resident's entire body to determine if skin impairment is present. Findings of the examination will be documented in the Summary section of the Admission Nursing Database and on the Individual Skin Grids... 3. Ongoing assessment will continue weekly with the Licensed Nurse completing a full body skin audit. Completion of the skin audit will be documented on the Treatment Administration Record (TAR) with their initials, and either a '-' or '+'...'+' indicates skin impairment. (Proceed to next step). 4. Upon discovery of newly identified skin impairment (abrasion, bruise, burn, excoriation, pressure sore, rash, skin tear, surgical wound, etc), the Licensed Nurse will: Document skin impairment that includes measurements of size, color, presence of odor and exudates. Document presence of pain associated with the skin impairment. Notify the physician and obtain a Treatment Order if needed, document on the TAR after implemented...Document findings on the ...Skin Grid for Non-Pressure Related Skin Impairment...Document all of previous actions and resident's response in the Progress Notes... 6. Weekly Wound Rounds are to be completed by a team consisting of the Director of Nursing Services (DNS)/Designee and Resident Care Manager's (RCM's). Arterial, Pressure, Stasis, Venous Ulcers and Surgical Wounds are to be assessed, measured and documented on the Skin Grid...." 1. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 12/27/13 Admission Nursing Database assessed Resident 1 as alert and oriented to person, place and time. The resident had a Foley catheter in place and [MEDICAL CONDITION] (swelling) to the scrotum, redness in color. At the time of the survey, there was no documented assessment of the resident's scrotal [MEDICAL CONDITION], including the extension and degree/measurement of the [MEDICAL CONDITION], completed at the time of admission. The 12/26/13 Admission Physician order [REDACTED]. The 12/27/13 Admission Initial Pain Questionnaire noted Resident 1 did not have pain at the time of the assessment. The 12/31/13 and 1/1/14 Progress Notes indicated scrotal [MEDICAL CONDITION] was noted, with no documented assessments of the [MEDICAL CONDITION]. The 1/2/14 CAA for pain noted the resident reported back and flank pain. The resident stated Tylenol was not working to take away the pain but he did not need any narcotics. "If resident has an increase in pain, the proper medication will be initiated." On 1/3/14 the physician ordered ice packs to the scrotum for 15 minutes, four times a day and as needed for pain/swelling. Per the 1/2014 TAR the ice packs were administered as ordered. According to the 1/2014 TAR, on 1/6/14 the Weekly Skin Check was documented as a "+." At the time of the survey, there was no documented assessment of the identified skin impairment. The 1/8/14 Physician History and Physical noted the resident had resolving scrotal [MEDICAL CONDITION], which was described as "mild" with no [DIAGNOSES REDACTED] (redness). No drainage was noted. The 1/8/14 Occupational Therapy Treatment Encounter Note indicated the resident reported the physician had just been in and "there was lots of drainage from cath site." Staff 26, Rehab Director/Occupational Therapist, "recommended change in brief as there was significant drainage from catheter site." On 1/9/14 the physician ordered [MEDICATION NAME] (a diuretic) 2 mg daily. According to the 1/2014 MAR, the [MEDICATION NAME] was given as ordered. Resident 1 did not receive the PRN Tylenol from 1/2/14 through 1/9/14. The 1/10/14 Occupational Therapy Treatment Encounter Note indicated the resident was able to stay up in the wheelchair for 30 minutes before being assisted back to bed. The 1/10/14 2:59 am and 1/11/14 2:27 am Progress Notes revealed Resident 1 complained of 6 out of 10 pain in the "prostate area" with Tylenol given. The 1/11/14 4:41 pm Progress Note disclosed Resident 1 had 8 out of 10 back pain, which decreased to 7 out of 10 after he was given Tylenol. An "increase" in pus was noted at the catheter insertion through the urinary tract. The resident complained of severe burning and pain as if "traveling up the catheter." The pus and urine was described as malodorous (foul smelling). On 1/11/14 the physician ordered a urinalysis with culture and susceptibility be obtained and ordered medications including [MEDICATION NAME] (an antibiotic) for a UTI (urinary tract infection) for seven days and [MEDICATION NAME] 5/325 one tablet every six hours as needed for pain. The 1/12/14 2:27 am and 1/13/14 4:16 am Progress Notes indicated the resident had 6 out of 10 pain in the prostate area. The 1/13/14 3:24 pm and 1/14/14 3:21 pm Progress Note disclosed a small amount of pus was still noticeable at the tip of the penis. The resident denied pain in the urinary tract. On 1/14/14 the physician discontinued the [MEDICATION NAME] and ordered Bactrim for seven days. Per Staff 2's, DNS, summary of the resident's stay, the physician changed the antibiotic based on susceptibility for treating the UTI. The 1/2014 MAR noted on 1/16/14 at 5:00 am, Resident 1 was administered [MEDICATION NAME] for reported pain of 5 out of 10. The 1/16/14 Occupational Therapy Treatment Encounter Note, signed at 11:03 am, indicated "upon self propelling w/c (wheelchair) down to therapy gym, pt (patient) stated 'I need to go to the ER.' OT notified nursing, RCM came down to have discussion with pt regarding request. Nursing recommended pt. return to bed so she could assess situation." Resident 1 had 6 out of 10 scrotal pain and was up in the wheelchair approximately "20 min prior to having to return back to bed." The 1/16/14 2:39 pm Progress note revealed at 9:00 am, "observed scant bloody, purulent (containing pus) foul smelling discharge from penis, catheter care performed, unable to expose meatus..." (opening at the tip of the penis) due to tightening of the foreskin. The 1/16/14 Physical Therapy Treatment Encounter Note, signed at 2:22 pm, indicated during transfers "Pt unable to get more than 2 inch of clearance off bed. Trials 2x's." The resident became very painful in the scrotal area, reporting 8 out of 10 pain and needed to lay back down. After lying on his back and applying ice the resident reported a pain level of "3 1/2." It noted the resident's pain limited his functional activities. "Due to increased pain patient very resistant to moving around too much which irritates scrotal area....Time spent talking with charge nurse about patients status. Pt still very painful from this morning. At first pt unwilling to trial standing but with reassurance from therapist pt willing to trial if it didn't cause to (sic) much more pain." Staff 28, Physical Therapist, documented pain as a barrier during the session. On 1/16/14 the physician referred Resident 1 to a urologist for scrotal/meatal [MEDICAL CONDITION]. At the time of the survey, there was no documented thorough assessment of the resident's status, including the extension, degree and measurement of the scrotal [MEDICAL CONDITION], the skin integrity of the penis when the resident was noted to have a change in condition to the scrotal area and the impact pain was having on therapy. There was no documented evidence alert charting had been initiated, nor was there documented follow up of the resident's request to be sent to the emergency room . The 1/2014 MAR noted on 1/16/14 at 9:40 pm, Resident 1 received [MEDICATION NAME] for reported pain of 7 out of 10 and on 1/17/14 at 10:00 am for a pain level of 6 out of 10. Staff 28, Physical Therapist, documented on the 1/17/14 Physical Therapy Treatment Encounter Note "Spoke with RCM about patients pain in groin area. Pt fearful of causing more pain with bed mobility and transfers. Held transfer/bed mobility training today..." The 1/18/14 1:47 am Progress Note revealed Resident 1 complained of 6 out of 10 pain, "given prn [MEDICATION NAME]" There was no correlating documentation regarding the administration of the [MEDICATION NAME] on either the 1/2014 MAR or the Narcotic Record. 1/18/14 and 1/19/14 Progress Notes indicated physical and occupational therapies were not scheduled for Resident 1 on those days. The 1/19/14 1:09 am Progress Note indicated Resident 1 complained of 9 out of 10 pain, which was treated with [MEDICATION NAME]. The 1/20/14 2:26 am Progress Note revealed the resident had "scant" amount of blood noted in the brief and around the meatus. Resident 1's Narcotic Record noted the resident received [MEDICATION NAME] on 1/20/14 at 10:30 am. There was no further documentation on the MAR or the Progress Notes regarding the administration of the medication nor the resident's pain level. The 1/20/14 12:41 pm Progress Note revealed paramedics arrived at 11:30 am after receiving a call from a friend of Resident 1. The resident agreed to go with the paramedics, "no MD orders received, AMA (against medical advice) paperwork signed." At the time of the survey, there was no documented assessment of Resident 1's scrotal [MEDICAL CONDITION], including the condition of his penis when the resident left with paramedics on 1/20/14. At the time of the survey, the resident had not returned to the facility. The 1/20/14 Emergency Department Encounter Note, signed by Witness 4, Physician on 1/24/14, indicated Resident 1 presented to the Emergency Department with pus like drainage from around the penis with a necrotic appearing penis, which was described as "grayish black." "He is a diabetic and clearly is at risk for serious soft tissue infections including necrotizing fascitis (a bacterial infection). After my initial evaluation of the patient [MEDICAL CONDITION] protocol was promptly initiated...Antibiotics were promptly ordered that [MEDICAL CONDITION] doses...I immediately put a call out to general surgery...because of my concern for necrotizing fascitis/fourniers (a type of gangrene that involves the genital organs)." Per the report, one of the surgeons contacted requested a CT scan. "I expedited that CT by having the charge nurse call CT to let her know we needed to get this study emergently and I spoke to the CT technician as well to express my need for an emergent scan. Meanwhile, we continued treatment for [REDACTED]. nauseated and then promptly became unresponsive...chest compressions were initiated....After 2 minutes of chest compressions a weak pulse was felt centrally." It was decided "to further stabilize him in the intensive care unit prior to going to the operating room. The patient was admitted to the ICU in extremely critical condition." The 1/25/14 Discharge Summary noted a pathology report from 1/20/14 revealed "Penile tissue showing extensive necrosis and acute inflammation consistent with necrotizing fascitis." Procedures included a total penectomy (surgical removal of the penis). The resident was discharged to a local hospital burn center for further treatment. In interview on 3/14/14 at 10:35 am, Witness 1, Complainant, stated Resident 1 did not normally complain of pain, but was reporting a lot of it and when he reported it, he was in significant pain. The resident could only sit in his wheelchair for a couple of minutes. The resident asked to be sent to the emergency roiagnom on at least two occasions. Witness 1 stated on 1/16/14, she had cleaned the resident up herself when Resident 1 had bleeding and foul smelling pus. Witness 1 stated she informed Staff 7, RN, that Resident 1's brief was all full of blood and smelled really bad. When asked if Staff 7 assessed the resident at that time, Witness 1 stated "no." In interview on 3/10/14 at 10:02 am, Resident 1 stated he was "pleading" with staff to get him to a physician for approximately 10 days. He stated he wanted to go to the ER, but staff turned him down on that request. Resident 1 reported he had tremendous amount of pain and wanted to go back to bed after therapy would transfer him to the wheelchair. Resident 1 stated he was clear at the time, but the closer he came to being taken out of the facility by ambulance, the foggier he became. Per Resident 1, Witness 6, Family, called paramedics for him. In interview on 3/14/14 at 11:00 am, Witness 6, Family, stated she had spoken with Resident 1 and Witness 1, Complainant, and Resident 1 was having a lot of bleeding and pus issues for approximately a week or so before going to the hospital. Witness 6 stated when she spoke on the phone with Resident 1 on 1/20/14, Resident 1 was short of breath and reported bleeding during his shower . Witness 6 stated she called 911 and reported the resident was losing blood and having breathing problems. In interview on 3/14/14 at 11:36 am, Staff 11, RN, stated he was not sure if the resident's scrotal [MEDICAL CONDITION] was assessed daily or weekly. The weekly assessments were documented on the TAR. CNA staff observed the area every day and if anything was abnormal they would report it to the nurse so it could be assessed. Staff 11 stated CNA staff reported changes to the resident on 1/16/14. When Staff 11 observed the resident's scrotal [MEDICAL CONDITION] and penis on 1/16/14, he "did not know what to make of it." Staff 11 stated the penis had a "dusky color", which he stated he forgot to document, the foreskin was really tight, he could not expose the meatus and he had never seen anything like that before. Staff 11 stated he had Staff 3, RNCM, observe the area and Staff 3 arranged for a urology appointment for the resident. Staff 11 stated it was "definitely a change" for the resident, which he described as "unusual." Staff 11 stated the resident complained of pain more often just prior to going to the hospital. When asked if Resident 1 had requested to see a physician or go to the hospital, Staff 11 stated "not directly." Per Staff 11, Resident 1 stated something seemed wrong and something should be done about it. In interviews on 3/14/14 at 12:24 pm and 3/24/14 at 10:00 am, Staff 7, RN, stated the resident was not good about reporting pain, and would report pain when it was out of control or she would learn of it second hand from family. Staff 7 stated she participated in Resident 1's admission intake in 12/2013. Staff 7 stated initially the resident had [MEDICAL CONDITION] from the testicles into the penis. Staff 7 stated when she documented the "+" on the 1/6/14 skin check, she did not initiate a Skin Grid for further documentation as her finding was related to the resident's penis, which staff were already monitoring. Staff 7 stated there was more discharge and there was increased swelling to the tip of the penis. The discharge did not have the odor that occurred later. Per Staff 7, later there were concerns the foreskin was no longer able to be retracted and there was discoloration at the tip of the penis. Staff 7 stated the penis tissue was changing in color, the tip turned white, which was non-blanchable, which started with small white patches that became larger, nothing that anyone had ever seen before. Staff 7 stated she discussed her concerns of the discoloration, not being able to retract the foreskin, and possible infection and strangulation of the penis, which were not going away and was becoming more painful for the resident, with Staff 2, DNS and Staff 3, RNCM on at least two occasions. Staff 7 stated she had those discussions with Staff 2 and 3 both the week prior and a few days prior to the resident being sent out to the hospital. Staff 7 stated she did not call the physician herself about the resident's status as it was protocol to inform Staff 2 or Staff 3 for follow up. Staff 7 stated there was a statement from the resident about wanting to see a physician. The resident had an appointment with a urologist and she thought the facility was also working on the resident being seen by the facility physician. Per Staff 7, on 1/19/14 she told Staff 3 there was a change in discharge odor and the area was more reddened. In interview on 3/14/14 at 12:47 pm, Staff 12, CNA, stated while providing catheter care, he observed the resident's scrotal area/penis was very swollen. On 1/16/14 he was not able to clean the resident's foreskin. Staff 12 stated the discharge coming out of the resident's penis had an odor, which increased during the resident's stay in the facility. Staff 12 stated the resident asked to see the nurse, then the resident would ask the nurse about seeing the physician that came to the facility. Staff 12 was unable to recall when Resident 1 made those requests. In interview on 3/14/14 at 1:29 pm, Staff 8, RN, stated Resident 1 had some infection starting, which was not clearly identifiable, no one knew what was going on. The foreskin was swollen and the physical assessment was difficult to do because of the foreskin swelling. At one point she had Staff 3, RNCM, assess the resident's penis, which did not look normal. Staff 8 stated Resident 1's penis appeared to have a white area on the meatus, two spots that were the size of "the tip of a pencil." The next time Staff 8 visualized the area, the white spots were spreading and the entire tip of the penis was white. Staff 8 stated she could not see the insertion point of the catheter because the foreskin was swollen tight. Staff 8 stated when she visualized the changes, she had never seen anything like it before. Staff 8 stated the changes to the discoloration were over the course of a week to a week and a half, just before the resident went to the hospital. Staff 8 stated there was drainage from the urethra/penis, which occurred off and on. At one point the resident had some blood coming out of the catheter point while the resident was sitting on a toilet. Staff 8 stated she was not under the impression she had to update the Skin Grid every time she went in and visualized the penis/scrotal area and did not document her assessments. Staff 8 stated she did not contact the physician directly regarding the resident's status, but informed Staff 3. In interview on 3/14/14 at 2:26 pm, Staff 21, CNA, stated Resident 1's penis was very swollen and staff had to make sure they provided the catheter care because of the drainage. Staff 21 stated he checked on the resident's drainage twice an hour as he would try to control the odor and the smell of the resident's room. Staff 21 described the drainage as sometimes a little, sometimes a lot and at times blood was mixed with the drainage. Staff 21 stated the resident asked to go to the hospital or see a physician, which he reported to the nurse, but he could not recall when or how often the resident made the request. The resident's pain level depended on the day, sometimes it was okay, other times it was totally painful when he provided peri care for the resident. In interview on 3/17/14 at 1:35 pm, Staff 5, RN, stated she was off schedule for four days and upon her return learned the resident had left the facility AMA. Staff 5 stated on one occasion when she had assessed Resident 1's scrotal area, there was scant bleeding and the penis was really swollen, but it was hard to visualize because of the swelling. Staff 5 stated it was a known thing by the day nurse and Staff 3, RNCM. As the night nurse she checked it and passed the information along. In interviews on 3/24/14 at 10:08 am and 3/25/14 at 10:13 am, Staff 26, Rehab Director/Occupational Therapist, stated when Resident 1 was initially admitted to the facility, he had pain, but by 1/6/14 the pain was declining. On 1/10/14 the resident was able to tolerate sitting in the wheelchair for 30 minutes before going back to bed and he was doing a little better in functional skills. On 1/15/14 to 1/16/14 the resident started to decline again in functional skills due to a higher increase in scrotal pain. On 1/16/14 the resident reported he was painful prior to therapy but he was willing to try to get up in the wheelchair. He reported a pain level of 6 out of 10 in the scrotal area just from being up in the wheelchair for 20 minutes. On the way down to the therapy gym, the resident stated he thought he needed to go to the emergency room . Staff 26 stated she asked the resident a couple of times if he wanted to go to the hospital "right now", to which the resident responded "yes." Staff 26 stated she got Staff 3, RNCM, and all three of them went into the therapy gym. The resident expressed his concerns that he thought he needed another procedure to release pressure in the scrotal area. Staff 3 had the resident lie down in bed so she could assess the area. In interview on 3/24/14 at 2:47 pm, Staff 28, Physical Therapist, stated Resident 1 was "pretty painful" before he went to the hospital and they did certain things to accommodate the pain. Staff 28 stated the resident had pain at admission, he did better for about a week, then the pain started "ramping up again." The resident's groin was very swollen and painful. Staff 28 stated she spoke with Staff 3, RNCM, about the resident's pain, who stated they would check into it. In interviews on 3/17/14 at 11:33 am and 3/19/14 at 11:37 am, Staff 22, CNA, stated when Resident 1 was first admitted to the facility he was really quiet and did not voice any concerns regarding pain. Per Staff 22, the resident began reporting pain a week to a week and a half before going to the hospital. Staff 22 stated on the day before the hospitalization (1/19/14) and the day of the hospitalization (1/20/14), Resident 1 was having a lot of pain and he wanted to know what they were doing for him or if he should go to the hospital. Staff 22 stated the resident had bleeding before, during and after a shower on 1/20/14, which Staff 22 described as continuous, like a slow dripping faucet. Staff 22 stated she reported the bleeding to Staff 25, RN, several times that day. Staff 22 stated she placed a basin under the resident's shower chair to catch the bleeding. During the resident's shower, Staff 25, RN, came down to the shower room, looked at the resident's penis and the blood in the basin and left. Per Staff 22, Resident 1 was pretty upset about the bleeding and wanted to know what staff were doing to address it. Staff 22 stated the resident was normally pretty easy going but at this time he was getting more distraught. Staff 22 stated the resident's friend called, he told his friend he was having some problems and not feeling very good. The resident's friend offered to get him and take him to the hospital, but the resident said he could not leave AMA, and the friend called 911. In interviews on 3/24/14 at 11:36 am and 3/25/14 at 3:50 pm and 4:48 pm Staff 25 RN, stated when she documented about the "increased drainage" on 1/11/14, the scrotal area was very swollen and the meatus was "very strange", it was retracted a little bit but she could not recall any discoloration of the penis. Staff 25 stated later there was more drainage and the resident started bleeding, but she could not recall when the bleeding started. Staff 25 stated they knew things were progressively getting worse and she thought they were communicating with Staff 3, RNCM, and the physician. Staff 25 stated Staff 8, RN, had previously told her Staff 8 had observed some white spots on the resident's penis. However, Staff 25 stated it was hard to tell because the foreskin was so retracted. Staff 25 stated she reported to the physician it was hard to assess the area because she could not see what was going on. Staff 25 stated the resident's condition was really different, something she was not used to dealing with. Staff 25 stated on 1/20/14 a CNA told her the resident was bleeding, which the CNA showed her. The resident was having a "good amount of blood" loss from his penis, around the catheter, more than a normal amount and she notified the physician. The meatus was swollen and she could not remember if there was any discoloration to the penis. When asked about the documentation of her findings, Staff 25 stated charting was a little bit difficult as she charted whatever she could remember at the end of the shift. Staff 25 stated she spoke with Staff 3 about the resident's condition and Staff 3 did not want to send the resident out to the hospital. Staff 25 stated she did not think Staff 3 understood the severity of the resident's condition, "I don't think anyone realized it was that severe." Staff 25 stated they shared with the physician about the drainage, the pus and the bleeding, but before they could do anything about it the resident's friend called for an ambulance. In interview on 3/18/14 at 11:48 am and 3/25/14 at 10:20 am Staff 3, RNCM, stated she was not aware of the discoloration of the resident's penis as observed by nursing staff. At one point the resident did not participate in therapy because of pain or did minimal participation, but she could not recall when that occurred. Staff 26, Rehab Director/Occupational Therapist, asked about the resident's scrotal swelling, which she informed Staff 26 was chronic. Staff 3 stated at one point the resident requested to see the physician the next time he was in, but she could not recall when the resident made that request. Staff 3 stated prior to 1/16/14, she knew Resident 1 was being treated for [REDACTED]. Staff 3 stated Staff 11, RN, reported to her on 1/16/14 Resident 1 had increased drainage and swelling. Staff 3 stated she went to the resident's room with Staff 11 and assessed the resident's scrotal area/penis. The scrotum was very enlarged and she could not recall any discoloration of the penis. When asked about the resident's request to go to the emergency roiagnom on [DATE], Staff 3 stated she did not recall being informed of that request. The resident was having pain, she went to the therapy gym, had the resident lie down and she assessed the resident's scrotal area. Staff 3 stated she called the physician, who referred the resident to a urologist. Staff 3 stated she could not recall if she had reported the resident's pain, therapy participation and request to go to the emergency room to physician. On 1/20/14 she spoke with the resident about his concerns regarding getting an earlier appointment with the urologist. At that time, the resident had an increase in pain overall, the scrotal swelling had increased and there was quite a bit of drainage but she could not recall if there was any discoloration of the penis. Staff 3 stated she was not aware Resident 1 had bleeding on 1/20/14. The physician wanted to change treatment to a stronger antibiotic that day, however, the resident talked to his friend, who called 911. Due to having no orders for the resident to go to the hospital, she had the resident sign AMA paperwork. At the time of the survey, Staff 3 did not provide documentation of either the 1/16/14 or 1/20/14 assessments. In interview on 3/18/14 at 1:09 pm, Staff 2, DNS, stated she was not aware of the discoloration and white spots on Resident 1's penis observed by nursing staff. Staff 2 stated she expected the facility's policy regarding documentation and communication be followed, documenting and reporting everything, so the staff reporting to the physician would have a clear picture. Staff 2 stated they relied on the physician for when he wanted to see a resident. Staff 2 stated there were no orders to send the resident to the hospital on [DATE]. In interview on 3/25/14 at 4:05 pm, Witness 5, Physician, stated nursing staff reported there was an abnormality of the resident's penis, but could not recall if staff reported there were white spots that worsened on the tip of the penis and did not know what to make of the 1/16/14 nurse's observation of the penis appearing dusky. Witness 5 stated he did not recall being informed of the resident's request to go to the Emergency Department. Witness 5 stated he had been told the resident's pain was "minimal to intermittent" from 1/16/14 until the day he left the facility. Witness 5 stated had he "been given the information there was progressive or pronounced pain, would want to get that assessed." When the resident had pain on the morning of 1/20/14, the resident was informed Witness 5 would see him that day, but the resident did not want to wait. Witness 5 stated he could not state if he was informed about the resident's bleeding on 1/20/14, but if there was a lot of pain and a lot of bleeding the resident should have been sent to the hospital via emergency services. Witness 5 stated he remembered telling staff to send the resident via emergency services because the resident was having too much pain and staff reported a friend wanted to take the resident out of the facility AMA (against medical advice). In interview on 3/13/14 at 9:00 pm, Witness 4, Emergency Department Physician, stated Resident 1's penis appeared "pretty necrotic" when he came into the Emergency Department. Witness 4 stated regarding necrotizing fascitis, "no matter where it is in the body is clearly time dependent for treatment, the sooner it is taken care of the better." 2. Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/9/14 Admission Physician order [REDACTED]. The 1/10/14 Admission Nursing Database noted Resident 1 was admitted with a lumbar surgical incision scab 8.5 x 0.4 cm with scant serosanganeous drainage, that was sealed with [MEDICATION NAME] glue. The 1/10/14 Skin Grid For All "Other" Skin Problems was initiated for the surgical wound status at admission. At the time of the survey, there were no further documented assessments of the surgical wound. The 1/11/14 Physician order [REDACTED]. The 1/13/14 Physician order [REDACTED]. On 1/14/14 the physician was informed the bactricin ointment was not available. The physician changed to treatment to a trip

Based on interview and record review it was determined the facility failed to honor the resident's right to seek medical attention for 1 of 4 sampled residents (#1) reviewed for changes in condition. As a result, Resident 1 did not receive medical attention in a timely manner, was hospitalized and required emergent treatment. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 12/27/13 Admission Nursing Database assessed Resident 1 as alert and oriented to person, place and time. The resident had a Foley catheter in place and [MEDICAL CONDITION] (swelling) to the scrotum, redness in color. The 1/8/14 Occupational Therapy Treatment Encounter Note indicated the resident reported the physician had just been in and "there was lots of drainage from cath site." Staff 26, Rehab Director/Occupational Therapist, "recommended change in brief as there was significant drainage from catheter site." The 1/10/14 2:59 am and 1/11/14 2:27 am Progress Notes revealed Resident 1 complained of 6 out of 10 pain in the "prostate area" with Tylenol given. The 1/11/14 4:41 pm Progress Note disclosed Resident 1 had 8 out of 10 back pain, which decreased to 7 out of 10 after he was given Tylenol. An "increase" in pus was noted at the catheter insertion through the urinary tract. The resident complained of severe burning and pain as if "traveling up the catheter." The pus and urine was described as malodorous (foul smelling). On 1/11/14 the physician ordered a urinalysis with culture and susceptibility be obtained and ordered medications including [MEDICATION NAME] (an antibiotic) for a UTI (urinary tract infection) for seven days and [MEDICATION NAME] 5/325 one tablet every six hours as needed for pain. The 1/12/14 2:27 am and 1/13/14 4:16 am Progress Notes indicated the resident had 6 out of 10 pain in the prostate area. The 1/13/14 3:24 pm and 1/14/14 3:21 pm Progress Note disclosed a small amount of pus was still noticeable at the tip of the penis. The resident denied pain in the urinary tract. On 1/14/14 the physician discontinued the [MEDICATION NAME] and ordered Bactrim for seven days. Per Staff 2's, DNS, summary of the resident's stay, the physician changed the antibiotic based on susceptibility for treating the UTI. The 1/2014 MAR indicated [REDACTED]. The 1/16/14 Occupational Therapy Treatment Encounter Note, signed at 11:03 am, indicated "upon self propelling w/c (wheelchair) down to therapy gym, pt (patient) stated 'I need to go to the ER.' OT notified nursing, RCM came down to have discussion with pt regarding request. Nursing recommended pt. return to bed so she could assess situation." Resident 1 had 6 out of 10 scrotal pain and was up in the wheelchair approximately "20 min prior to having to return back to bed." The 1/16/14 2:39 pm Progress note revealed at 9:00 am, "observed scant bloody, purulent (containing pus) foul smelling discharge from penis, catheter care performed, unable to expose meatus..." (opening at the tip of the penis) due to tightening of the foreskin. At the time of the survey there was no documented follow up of the resident's request to be sent to the emergency room . The 1/16/14 Physical Therapy Treatment Encounter Note, signed at 2:22 pm, indicated during transfers "Pt unable to get more than 2 inch of clearance off bed. Trials 2x's." The resident became very painful in the scrotal area, reporting 8 out of 10 pain and needed to lay back down. After lying on his back and applying ice the resident reported a pain level of "3 1/2." It noted the resident's pain limited his functional activities. "Due to increased pain patient very resistant to moving around too much which irritates scrotal area....Time spent talking with charge nurse about patients status. Pt still very painful from this morning. At first pt unwilling to trial standing but with reassurance from therapist pt willing to trial if it didn't cause to (sic) much more pain." Staff 28, Physical Therapist, documented pain as a barrier during the session. The 1/2014 MAR indicated [REDACTED]. Staff 28, Physical Therapist, documented on the 1/17/14 Physical Therapy Treatment Encounter Note "Spoke with RCM about patients pain in groin area. Pt fearful of causing more pain with bed mobility and transfers. Held transfer/bed mobility training today..." The 1/18/14 1:47 am Progress Note revealed Resident 1 complained of 6 out of 10 pain, "given prn [MEDICATION NAME]" There was no correlating documentation regarding the administration of the [MEDICATION NAME] on either the 1/2014 MAR indicated [REDACTED] 1/18/14 and 1/19/14 Progress Notes indicated physical and occupational therapies were not scheduled for Resident 1 on those days. The 1/19/14 1:09 am Progress Note indicated Resident 1 complained of 9 out of 10 pain, which was treated with [MEDICATION NAME]. Resident 1's Narcotic Record noted the resident received [MEDICATION NAME] on 1/20/14 at 10:30 am. There was no further documentation on the MAR indicated [REDACTED]. The 1/20/14 12:41 pm Progress Note revealed paramedics arrived at 11:30 am after receiving a call from a friend of Resident 1. The resident agreed to go with the paramedics, "no MD orders received, AMA (against medical advice) paperwork signed." The 1/20/14 Release From Responsibility For Discharge form noted the resident understood "the consequences" and left "against the advice of the attending physician and facility administrator." At the time of the survey, the resident had not returned to the facility. The 1/20/14 Emergency Department Encounter Note, signed by Witness 4, Physician on 1/24/14, indicated Resident 1 presented to the Emergency Department with pus like drainage from around the penis with a necrotic appearing penis, which was described as "grayish black." "He is a diabetic and clearly is at risk for serious soft tissue infections including [DIAGNOSES REDACTED] (a bacterial infection). After my initial evaluation of the patient [MEDICAL CONDITION] protocol was promptly initiated...Antibiotics were promptly ordered that [MEDICAL CONDITION] doses...I immediately put a call out to general surgery...because of my concern for [DIAGNOSES REDACTED]/fourniers (a type of gangrene that involves the genital organs)." Per the report, one of the surgeons contacted requested a CT scan. "I expedited that CT by having the charge nurse call CT to let her know we needed to get this study emergently and I spoke to the CT technician as well to express my need for an emergent scan. Meanwhile, we continued treatment for [REDACTED]. nauseated and then promptly became unresponsive...chest compressions were initiated....After 2 minutes of chest compressions a weak pulse was felt centrally." It was decided "to further stabilize him in the intensive care unit prior to going to the operating room. The patient was admitted to the ICU in extremely critical condition." The 1/25/14 Discharge Summary noted a pathology report from 1/20/14 revealed "Penile tissue showing extensive necrosis and acute inflammation consistent with [DIAGNOSES REDACTED]." Procedures included a total penectomy (surgical removal of the penis). The resident was discharged to a local hospital burn center for further treatment. In interview on 3/14/14 at 10:35 am, Witness 1, Complainant, stated Resident 1 did not normally complain of pain, but was reporting a lot of it and when he reported it, he was in significant pain. The resident could only sit in his wheelchair for a couple of minutes. The resident asked to be sent to the emergency roiagnom on at least two occasions. Witness 1 stated on 1/16/14, she had cleaned the resident up herself when Resident 1 had bleeding and foul smelling pus. Witness 1 stated she informed Staff 7, RN, that Resident 1's brief was all full of blood and smelled really bad. When asked if Staff 7 assessed the resident at that time, Witness 1 stated "no." In interview on 3/10/14 at 10:02 am, Resident 1 stated he was "pleading" with staff to get him to a physician for approximately 10 days. He stated he wanted to go to the ER, but staff turned him down on that request. Resident 1 reported he had tremendous amount of pain and wanted to go back to bed after therapy would transfer him to the wheelchair. Resident 1 stated he was clear at the time, but the closer he came to being taken out of the facility by ambulance, the foggier he became. Per Resident 1, Witness 6, Family, called paramedics for him. In interview on 3/14/14 at 11:00 am, Witness 6, Family, stated she had spoken with Resident 1 and Witness 1, Complainant, and Resident 1 was having a lot of bleeding and pus issues for approximately a week or so before going to the hospital. Witness 6 stated when she spoke on the phone with Resident 1 on 1/20/14, Resident 1 was short of breath and reported bleeding during his shower. Witness 6 stated she called 911 and reported the resident was losing blood and having breathing problems. In interview on 3/14/14 at 11:36 am, Staff 11, RN, stated CNA staff reported changes to the resident on 1/16/14. When Staff 11 observed the resident's scrotal [MEDICAL CONDITION] and penis on 1/16/14, he "did not know what to make of it." Staff 11 stated the penis had a "dusky color", which he stated he forgot to document, the foreskin was really tight, he could not expose the meatus and he had never seen anything like that before. Staff 11 stated he had Staff 3, RNCM, observe the area and Staff 3 arranged for a urology appointment for the resident. Staff 11 stated it was "definitely a change" for the resident, which he described as "unusual." Staff 11 stated the resident complained of pain more often just prior to going to the hospital. When asked if Resident 1 had requested to see a physician or go to the hospital, Staff 11 stated "not directly." Per Staff 11, Resident 1 stated something seemed wrong and something should be done about it. In interviews on 3/14/14 at 12:24 pm and 3/24/14 at 10:00 am, Staff 7, RN, stated the resident was not good about reporting pain, and would report pain when it was out of control or she would learn of it second hand from family. Staff 7 stated she participated in Resident 1's admission intake in 12/2013. Staff 7 stated initially the resident had [MEDICAL CONDITION] from the testicles into the penis. Per Staff 7, later there were concerns the foreskin was no longer able to be retracted and there was discoloration at the tip of the penis. Staff 7 stated the penis tissue was changing in color, the tip turned white, which was non-blanchable, which started with small white patches that became larger, nothing that anyone had ever seen before. Staff 7 stated she discussed her concerns of the discoloration, not being able to retract the foreskin, and possible infection and strangulation of the penis, which were not going away and was becoming more painful for the resident, with Staff 2, DNS and Staff 3, RNCM on at least two occasions. Staff 7 stated she had those discussions with Staff 2 and 3 both the week prior and a few days prior to the resident being sent out to the hospital. Staff 7 stated she did not call the physician herself about the resident's status as it was protocol to inform Staff 2 or Staff 3 for follow up. Staff 7 stated there was a statement from the resident about wanting to see a physician. The resident had an appointment with a urologist and she thought the facility was also working on the resident being seen by the facility physician. Per Staff 7, on 1/19/14 she told Staff 3 there was a change in discharge odor and the area was more reddened. In interview on 3/14/14 at 12:47 pm, Staff 12, CNA, stated while providing catheter care, he observed the resident's scrotal area/penis was very swollen. On 1/16/14 he was not able to clean the resident's foreskin. Staff 12 stated the discharge coming out of the resident's penis had an odor, which increased during the resident's stay in the facility. Staff 12 stated the resident asked to see the nurse, then the resident would ask the nurse about seeing the physician that came to the facility. Staff 12 was unable to recall when Resident 1 made those requests. In interview on 3/14/14 at 1:29 pm, Staff 8, RN, stated Resident 1 had some infection starting, which was not clearly identifiable, no one knew what was going on. The foreskin was swollen and the physical assessment was difficult to do because of the foreskin swelling. At one point she had Staff 3, RNCM, assess the resident's penis, which did not look normal. Staff 8 stated Resident 1's penis appeared to have a white area on the meatus, two spots that were the size of "the tip of a pencil." The next time Staff 8 visualized the area, the white spots were spreading and the entire tip of the penis was white. Staff 8 stated she could not see the insertion point of the catheter because the foreskin was swollen tight. Staff 8 stated when she visualized the changes, she had never seen anything like it before. Staff 8 stated the changes to the discoloration were over the course of a week to a week and a half, just before the resident went to the hospital. Staff 8 stated there was drainage from the urethra/penis, which occurred off and on. At one point the resident had some blood coming out of the catheter point while the resident was sitting on a toilet. In interview on 3/14/14 at 2:26 pm, Staff 21, CNA, stated Resident 1's penis was very swollen and staff had to make sure they provided the catheter care because of the drainage. Staff 21 stated he checked on the resident's drainage twice an hour as he would try to control the odor and the smell of the resident's room. Staff 21 described the drainage as sometimes a little, sometimes a lot and at times blood was mixed with the drainage. Staff 21 stated the resident asked to go to the hospital or see a physician, which he reported to the nurse, but he could not recall when or how often the resident made the request. In interviews on 3/24/14 at 10:08 am and 3/25/14 at 10:13 am, Staff 26, Rehab Director/Occupational Therapist, stated when Resident 1 was initially admitted to the facility, he had pain, but by 1/6/14 the pain was declining. On 1/10/14 the resident was able to tolerate sitting in the wheelchair for 30 minutes before going back to bed and he was doing a little better in functional skills. On 1/15/14 to 1/16/14 the resident started to decline again in functional skills due to a higher increase in scrotal pain. On 1/16/14 the resident reported he was painful prior to therapy but he was willing to try to get up in the wheelchair. He reported a pain level of 6 out of 10 in the scrotal area just from being up in the wheelchair for 20 minutes. On the way down to the therapy gym, the resident stated he thought he needed to go to the emergency room . Staff 26 stated she asked the resident a couple of times if he wanted to go to the hospital "right now", to which the resident responded "yes." Staff 26 stated she got Staff 3, RNCM, and all three of them went into the therapy gym. The resident expressed his concerns that he thought he needed another procedure to release pressure in the scrotal area. Staff 3 had the resident lie down in bed so she could assess the area. In interview on 3/24/14 at 2:47 pm, Staff 28, Physical Therapist, stated Resident 1 was "pretty painful" before he went to the hospital and they did certain things to accommodate the pain. Staff 28 stated the resident had pain at admission, he did better for about a week, then the pain started "ramping up again." The resident's groin was very swollen and painful. Staff 28 stated she spoke with Staff 3, RNCM, about the resident's pain, who stated they would check into it. In interviews on 3/17/14 at 11:33 am and 3/19/14 at 11:37 am, Staff 22, CNA, stated when Resident 1 was first admitted to the facility he was really quiet and did not voice any concerns regarding pain. Per Staff 22, the resident began reporting pain a week to a week and a half before going to the hospital. Staff 22 stated on the day before the hospitalization (1/19/14) and the day of the hospitalization (1/20/14), Resident 1 was having a lot of pain and he wanted to know what they were doing for him or if he should go to the hospital. Staff 22 stated the resident had bleeding before, during and after a shower on 1/20/14, which Staff 22 described as continuous, like a slow dripping faucet. Staff 22 stated she reported the bleeding to Staff 25, RN, several times that day. Staff 22 stated she placed a basin under the resident's shower chair to catch the bleeding. During the resident's shower, Staff 25, RN, came down to the shower room, looked at the resident's penis and the blood in the basin and left. Per Staff 22, Resident 1 was pretty upset about the bleeding and wanted to know what staff were doing to address it. Staff 22 stated the resident was normally pretty easy going but at this time he was getting more distraught. Staff 22 stated the resident's friend called, he told his friend he was having some problems and not feeling very good. The resident's friend offered to get him and take him to the hospital, but the resident said he could not leave AMA, and the friend called 911. In interviews on 3/24/14 at 11:36 am and 3/25/14 at 3:50 pm and 4:48 pm Staff 25 RN, stated when she documented about the "increased drainage" on 1/11/14, the scrotal area was very swollen and the meatus was "very strange", it was retracted a little bit but she could not recall any discoloration of the penis. Staff 25 stated later there was more drainage and the resident started bleeding, but she could not recall when the bleeding started. Staff 25 stated they knew things were progressively getting worse and she thought they were communicating with Staff 3, RNCM, and the physician. Staff 25 stated Staff 8, RN, had previously told her Staff 8 had observed some white spots on the resident's penis. However, Staff 25 stated it was hard to tell because the foreskin was so retracted. Staff 25 stated she reported to the physician it was hard to assess the area because she could not see what was going on. Staff 25 stated the resident's condition was really different, something she was not used to dealing with. Staff 25 stated on 1/20/14 a CNA told her the resident was bleeding, which the CNA showed her. The resident was having a "good amount of blood" loss from his penis, around the catheter, more than a normal amount and she notified the physician. The meatus was swollen and she could not remember if there was any discoloration to the penis. When asked about the documentation of her findings, Staff 25 stated charting was a little bit difficult as she charted whatever she could remember at the end of the shift. Staff 25 stated she spoke with Staff 3 about the resident's condition and Staff 3 did not want to send the resident out to the hospital. Staff 25 stated she did not think Staff 3 understood the severity of the resident's condition, "I don't think anyone realized it was that severe." Staff 25 stated they shared with the physician about the drainage, the pus and the bleeding, but before they could do anything about it the resident's friend called for an ambulance. In interview on 3/18/14 at 11:48 am and 3/25/14 at 10:20 am Staff 3, RNCM, stated she was not aware of the discoloration of the resident's penis as observed by nursing staff. At one point the resident did not participate in therapy because of pain or did minimal participation, but she could not recall when that occurred. Staff 3 stated at one point the resident requested to see the physician the next time he was in, but she could not recall when the resident made that request. Staff 3 stated prior to 1/16/14, she knew Resident 1 was being treated for [REDACTED]. Staff 3 stated Staff 11, RN, reported to her on 1/16/14 Resident 1 had increased drainage and swelling. Staff 3 stated she went to the resident's room with Staff 11 and assessed the resident's scrotal area/penis. The scrotum was very enlarged and she could not recall any discoloration of the penis. When asked about the resident's request to go to the emergency roiagnom on [DATE], Staff 3 stated she did not recall being informed of that request. The resident was having pain, she went to the therapy gym, had the resident lie down and she assessed the resident's scrotal area. Staff 3 stated she called the physician, who referred the resident to a urologist. Staff 3 stated she could not recall if she had reported the resident's pain, therapy participation and request to go to the emergency room to physician. On 1/20/14 she spoke with the resident about his concerns regarding getting an earlier appointment with the urologist. At that time, the resident had an increase in pain overall, the scrotal swelling had increased and there was quite a bit of drainage but she could not recall if there was any discoloration of the penis. Staff 3 stated she was not aware Resident 1 had bleeding on 1/20/14. The physician wanted to change treatment to a stronger antibiotic that day, however, the resident talked to his friend, who called 911. Due to having no orders for the resident to go to the hospital, she had the resident sign AMA paperwork. In interview on 3/25/14 at 4:05 pm, Witness 5, Physician, stated nursing staff reported there was an abnormality of the resident's penis, but could not recall if staff reported there were white spots that worsened on the tip of the penis and did not know what to make of the 1/16/14 nurse's observation of the penis appearing dusky. Witness 5 stated he did not recall being informed of the resident's request to go to the Emergency Department. Witness 5 stated he had been told the resident's pain was "minimal to intermittent" from 1/16/14 until the day he left the facility. Witness 5 stated had he "been given the information there was progressive or pronounced pain, would want to get that assessed." When the resident had pain on the morning of 1/20/14, the resident was informed Witness 5 would see him that day, but the resident did not want to wait. Witness 5 stated he could not state if he was informed about the resident's bleeding on 1/20/14, but if there was a lot of pain and a lot of bleeding the resident should have been sent to the hospital via emergency services. Witness 5 stated he remembered telling staff to send the resident out via emergency services because the resident was having too much pain and staff reported a friend wanted to take the resident out of the facility AMA (against medical advice). In interview on 3/13/14 at 9:00 pm, Witness 4, Emergency Department Physician, stated Resident 1's penis appeared "pretty necrotic" when he came into the Emergency Department. Witness 4 stated regarding [DIAGNOSES REDACTED], "no matter where it is in the body is clearly time dependent for treatment, the sooner it is taken care of the better." Refer to F309

Based on interview and record review it was determined the facility failed to implement care planned interventions to prevent falls for 1 of 3 residents (#1) who were at risk for falls. Resident 1 sustained a laceration to left eyebrow, was transported to the hospital and received sutures. Findings include: Resident 1 was admitted to the facility in 1/2010 with [DIAGNOSES REDACTED]. According to a 9/23/10 physical therapy (PT) evaluation the resident required contact assistance to walk in the parallel bars. According to a 10/5/10 nursing quarterly assessment the resident had weakness and difficulty with walking. The resident required the physical assistance of one person to walk in the facility. According to the current care plan the resident was a "High Risk" for falls. The care plan indicated that if the resident "requests to ambulate assist using (walker) and gait belt at all times." According to an "Incident/Accident Report," on 10/22/10 the resident was walking with Witness 1, on-call physical therapist, when the resident fell to floor and sustained a laceration to his left eyebrow. The resident was transported to the hospital and received sutures for the laceration. According to a written Witness Report completed by the physical therapist, the resident was walking with a walker with the physical therapist; when the resident attempt to turn, the resident fell forward on to the floor. The Witness Report indicated the resident "did not have a gait belt on (should have)". In an interview on 12/1/10 at 3:50 pm Witness 1 stated a gait belt was not needed when she walked with the resident on 10/22/10 because she had her hand on the resident. The witness stated she would use a gait belt if she walked with the resident again. In an interview on 12/1/10 at 3:00 pm Staff 1, physical therapist, stated that it was company policy that all physical therapists use a gait belt when walking with residents. Staff 1 stated a gait belt should be used with Resident 1; the resident had flexion contractures in the knees, had difficulty standing up straight and putting distance between feet. In an interview on 12/2/10 at 9:15 am Witness 1's failure to follow the resident's care plan for using a gait belt was discussed with Staff 2, Administrator. No additional information was provided.