Every finding on record at Rolling Hills Rehab and Care CTR

Based on observation, interview, review of facility temperature logs, and facility policies, the facility failed to safely store drugs at proper temperatures to preserve their integrity. Further, the facility failed to proper ensure controlled medications were stored in a separately locked, permanently affixed compartment. This affected four residents (Resident #13, 19, 25, and 42), and had the potential to affect all residents of the facility due to stock medications. Findings include:An observation of the North Medication Room on 07/08/26 from 7:06 A.M. to 7:45 A.M. revealed a medication refrigerator with a temperature of 50 degrees Fahrenheit. The refrigerator held resident medications and stock medications which could be used for any resident if ordered. There were two thermometers within the refrigerator confirming the temperature. All observations were confirmed by the Director of Nursing (DON) at the time of the observation. Medications stored in the refrigerator which affected specific residents included the following:a. Resident #13 had two Lantus Solostar Pens (insulin). Instructions for the medication were to store unopened in the refrigerator from 36 degrees Fahrenheit (F) to 46 degrees F until first use. Resident #13 also had Insulin Lispro Injection (10 milliliter (ml) vial). Instructions for the Insulin Lispro were to store unopened in the refrigerator at 36 degrees F to 46 degrees F until the expiration date. b. Resident #19 had four Lantus Solostar Pens. Instructions for the medication were to store unopened in the refrigerator from 36 degrees F to 46 degrees F until first use. c. Resident #25 had Insulin Glargine. Instructions for the medication were to store unopened in the refrigerator from 36 degrees F to 46 degrees F until expiration date or until first use. She also had a Pneumovax injection. The instructions for storage of the Pneumovax were to store refrigerated at 36 degrees F to 46 degrees F. Resident #25 had 13 Trulicity injection pens. Storage instructions were to store in the original carton at 36 degrees F to 46 degrees F. d. Resident #42 had two Novolog FlexPens in the refrigerator. Instructions for storage were to store unopened in the refrigerator from 36 degrees F to 46 degrees F until first use. The refrigerator also had medications indicated for stock use, which were medications which could be used for any resident in the event the physician ordered it and it was not immediately available to the resident or while waiting on the pharmacy to send the ordered medication to the facility. Stock medications which required storage at 36 degrees F to 46 degrees F included: Two Cathflo Activase; One Lorazepam Concentrate; One vial of Novolin N; Four Promethazine suppositories; One Lispro Vial; One Novolin R vial, One Novolin vial; Three Basaglar KwikPens; an one Lantus Solostar. There was a Tuberculin Purified Protein vial which was to be stored at 35 degrees F to 46 degrees F. The Lorazepam Concentrate 30ml was in a clear plastic box inside the medication refrigerator. The box had a lock on it; however, the lock was broken and the lid was not secured. The refrigerator was not locked. This was confirmed by the DON at the time of the observation. On 07/08/26 at 7:42 A.M., an interview with the DON revealed Lorazepam should be locked at all times due to being a controlled substance. She confirmed the box the Lorazepam concentrate was stored in was not locked or secured inside the medication refrigerator. She further confirmed all of the medications were to be stored at temperatures of 46 degrees F or below and the temperature in the medication refrigerator was 50 degrees F.Review of facility temperature log for July 2026 for the North medication refrigerator revealed temperatures on 07/07/26 with no time indicated. The temperature was 40 degrees F. Temperature on 07/08/26 (no time indicated) was listed as 40 degrees F. This log was confirmed by DON at 7:53 A.M.Review of a facility policy titled Storage of Medications, Revised April 2007, revealed the facility would store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff would be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. Medications requiring refrigeration must be stored in a refrigerator located in the drug room located at the nurse's station or other secured location. Medications must be stored separately from food and must be labeled accordingly. Review of a facility policy titled Controlled Substances, revised December 2012, revealed the facility would comply with all laws, regulations, and other requirements related to handling, storage, disposal and documentation of schedule two and other controlled substances. Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. The container must remained locked at all times, except when accessed to obtain medication for a resident.

Based on review of facility infection control logbook, review facility policy, and interview with the facility infection preventionist, the facility failed to maintain standardized surveillance of its antibiotic stewardship program. This had the potential to affect 52 residents residing in the facility. The facility census was 52. Findings Include: Review of the infection control logbook from January 2026 to July 2026 revealed a monthly log sheet containing a list of residents with infections, type of infection, type of organism if available, treatment ordered and completed, and available laboratory data. Further review of the logbook revealed blank copies of the McGeer's infection surveillance tool in the back of the logbook. There was no evidence of the McGeer's tool being filled out for any of the residents listed as having infections to ensure antibiotics prescribed were appropriate for the resident.The McGeer's criteria for infection surveillance tool is a standardized and nationally accepted tool used by health care facilities to establish standard definitions and criteria for infections and determine if residents meet the criteria to receive antibiotic therapy. The use of McGeer's tool is to assist facilities in preventing the overuse or unnecessary use of antibiotic therapy.Interview on 07/13/26 at 4:30 P.M. with the facility infection preventionist and assistant director of nursing (ADON) #700 revealed she did not have evidence of McGeer's being completed on each resident with a suspected infection and that she reviewed the criteria for infection following the McGeer's but did not actually complete the tool for each resident. ADON #700 verified since there was no evidence of the completion of the McGeer's for each individual resident with an infection it would be difficult to determine compliance with the antibiotic stewardship program.Review of the facility policy titled, Antibiotic Stewardship -Orders for Antibiotics, and revised 12/2016 revealed, appropriate indications for use of antibiotics include criteria met for clinical definition of active infection. Further review of Infection Prevention and Control Program section #8 (Antibiotic Stewardship), revised 10/2018 revealed, medical criteria and standardized definitions of infections are used to help recognize and manage infection. Antibiotic usage is evaluated and practitioners are provided feedback on review.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on review of medical records, review of facility policies, and interviews with facility staff, the facility failed to provide a comprehensive immunization program to ensure residents are offered and received immunizations timely. This affected four (Residents #9, #10, #20, and #26) of five residents reviewed for immunizations. The facility census was 52. Findings Include;1. Review of Resident #9 medical record revealed admission to facility on 11/05/19 for diagnoses including toxic encephalopathy (water on the brain), major depressive disorder, anemia (low blood count), dementia (confusion and forgetfulness), anxiety disorder, heart disease and high blood pressure. Further review of the medical record for Resident #9 revealed vaccination consents for the influenza vaccine, pneumonia vaccine, and covid-19 vaccine were dated for 05/12/26. 2.Review of Resident #10 medical record revealed admission to facility on 01/28/26 for diagnoses including alcoholic cirrhosis (liver damage), lung disease, diabetes, encephalopathy (water on the brain), anxiety, dementia, depression, heart failure, and kidney disease. Further review of the medical record for Resident #10 revealed vaccination consents for the influenza vaccine, pneumonia vaccine, and covid-19 vaccine were dated for 05/13/26. 3.Review of Resident #20 medical record revealed admission to facility on 10/03/25 for diagnosis including cellulitis of neck (infection of the skin), stroke with paralysis of one side, aphasia (inability to speak), high blood pressure, heart disease, and Alzheimer's disease (progressive confusion and forgetfulness). Further review of the medical record for Resident #20 revealed vaccination consents for the influenza vaccine, pneumonia vaccine, and covid-19 vaccine were dated for 06/11/26. 4.Review of the medical record for Resident #26 revealed admission to the facility on [DATE] for diagnoses including chronic respiratory failure, lung disease, diabetes, high blood pressure, depression, anxiety, heart disease, atrial fibrillation (irregular heartbeat), gastric reflux, schizoaffective disorder (paranoid personality tendences), and poor circulation in legs.Further review of the medical record for Resident #26 revealed vaccination consents for the influenza vaccine, pneumonia vaccine, and covid-19 vaccine were dated for 05/11/26. Interview on 07/13/26 at 10:57 A.M. with Director of Nursing (DON) revealed that she had found concerns with vaccine administration of residents shortly after starting her position on 02/27/26. The DON confirmed the consents were not obtained timely for Residents #9, #10, #20, and #26 and there was no evidence of those residents receiving the vaccinations in their medical records prior. The DON further reported that the facility immediately began a quality assurance performance improvement (QAPI) project upon discovery of the concerns to correct the situation and that ongoing monitoring continues.Review of the facility policy titled, Vaccination of Residents, and revised on 10/2016 revealed all residents will be offered vaccines that aide in preventing infectious disease and all new residents shall be assessed for current vaccination status on admission and receive education regarding benefits and side effects of vaccines provided by the facility and if they consent or decline them.The deficient practice was corrected on 006/25/26 when the facility implemented the following corrective actions. The QAPI plan dated 04/06/26 revealed the responsible party for completion of the plan was the DON. The plan included whole house audit and immunization updates, education to nursing staff entering immunizations not the computer, and scanning consents into computer upon admission. The QAPI plan further revealed a resolved dated of 06/25/26. Facility wide chart audits of all residents' vaccination status were reviewed by the DON on 04/26/26 reviewing resident records from 10/01/25 through 04/30/26. Ongoing weekly audits by the DON for all new admissions to the facility to ensure consents for vaccinations were completed and immunizations were entered in the medical records began on 05/11/26 and continued through 07/08/26 per the weekly audit tool verified. On 05/12/26 nursing staff including all LPNs and RNs were educated by the DON both verbally and in writing about obtaining vaccination status on all new admissions, completing consents for immunizations on admission an annually and entering into the vaccination status in the medical record. Staff sign-in sheets for education and training were verified.Review of the entire facility immunization report provided by the DON for Covid-19 vaccine and applicable boosters, influenza vaccine, and the pneumonia vaccines revealed all current residents vaccination status were updated in the electronic medical record.

Based on medical record review, policy review, and interview, the facility failed to notify a resident's representative of severe weight loss. This affected one (Resident #50) of three residents whose responsible parties were interviewed.Findings include: Review of Resident #50's medical record revealed diagnoses including Alzheimer's disease, stroke, type two diabetes, difficulty swallowing, depression, heart disease, and dementia with agitation. Review of a plan of care initiated 04/30/26 indicated Resident #50 had a nutritional problem related to decreased oral intake, therapeutic diet and mechanically altered diet. Interventions included monitoring intake and record every meal and monitor for significant weight loss. A weight of 203.9 pounds was recorded on 05/19/26. A weight of 193.4 pounds was recorded on 05/26/26, representing a 5.15% weight loss in one week. There was no documentation revealing Resident #50's responsible party was notified of the significant weight loss.Review of the facility's Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol (revised September 2012) revealed nursing staff were responsible for monitoring and documenting weights and dietary intake of residents in a format which permitted readily available comparisons over time. The protocol revealed a weight loss of greater than 5% within one month was identified as a severe weight loss.Review of the facility's Change in a Resident's Condition or Status policy (revised December 2016) described a significant change of condition as a major decline or improvement in the resident's status that would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, impacted more than one area of the resident's health status, required interdisciplinary review and/or revision to the care plan and ultimately was based on the judgment of the clinical staff. Unless otherwise instructed by the resident, a nurse would notify the resident's representative when there was a significant change in the resident's physical status. Except in medical emergencies, notifications would be made within 24 hours of a change occurring in the resident's condition. If a significant change in the resident's physical or mental condition occurred, a comprehensive assessment of the resident's condition would be conducted. On 07/09/26 at 6:00 P.M., the Director of Nursing (DON) verified she could not find documentation of the responsible party being notified of Resident #50's severe weight loss in May 2026.

Based on medical record review and interview, the facility failed to timely complete a significant change assessment for a resident who exhibited a severe weight loss and developed pressure ulcers since their prior assessment. This affected one (Resident #50) of 17 residents whose minimum data set (MDS) assessments and clinical records were reviewed for significant changes in condition.Findings include: Review of Resident #50's medical record revealed diagnoses including Alzheimer's disease, stroke, type two diabetes, difficulty swallowing, depression, heart disease, and dementia with agitation. An admission/Medicare five day MDS assessment dated [DATE] indicated Resident #50 was severely cognitively impaired. Resident #50 was assessed with no or unknown significant weight changes and had no unhealed pressure ulcers.A weight of 203.9 pounds was recorded on 05/19/26. A weight of 193.4 pounds was recorded on 05/26/26, representing a 5.15% weight loss in one week.Review of Resident #50's weekly wound observation dated 05/25/26 indicated Resident #50 had acquired a stage III pressure ulcer (full thickness skin injury that extends into the subcutaneous tissue) on bilateral buttocks.Review of the Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, revealed a significant change assessment should be completed by the 14th calendar day after the facility determined a significant change in the resident's status occurred. A significant change was described as a major decline or improvement in a resident's status that would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, impacted more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. During an interview on 07/10/26 at 11:12 A.M., Assistant Director of Nursing (ADON) #700 stated she was unaware of any Interdisciplinary Team (IDT) discussions to determine if Resident #50 should have a Significant Change MDS completed prior to initiation of hospice in July 2026.

Based on medical record review, observation and interviews with residents, and interviews with staff, the facility failed to provide activities of interest for Resident #26 and Resident #50. This affected two (Residents #26 and #50) of two residents reviewed for activities. The facility census was 52. Findings Include: 1.Review of the medical record for Resident #26 revealed admission to the facility on [DATE] for diagnoses including lung disease, diabetes, depression, anxiety, atrial fibrillation (irregular heartbeat), schizoaffective disorder (paranoid personality tendences), and poor circulation in legs. Further review of most recent (MDS) 3.0 annual comprehensive assessment completed on 08/13/25 for Resident #26 revealed that it was very important to the resident to go outside and get fresh air when the weather was good and very important for Resident #26 do things with groups of people. Review of the activities care plan dated 04/30/26 for Resident #26 revealed she was dependent on staff for meeting emotional, intellectual, and social needs and the resident would participate in activities of choice. Further review of the care plan for Resident #26 revealed interventions to invite the resident to scheduled activities and assist/escort resident to activities. Review of the most recent minimum data set (MDS) 3.0 quarterly assessment completed on 06/01/26 for Resident #26 revealed a brief interview for mental status (BIMS) score of 14/15 indicating cognitively intact. Resident #26 was noted to be dependent in a wheelchair for mobility and required partial to moderate assistance with personal care, dressing, and bathing. Review of the activity calendar for July 2026 revealed an outing planned on 07/03/26 for fireworks in the area. Observation and interview on 07/06/26 at 1:00 P.M. revealed she had concerns with the activities department and that the activities director (AD) #749 had stopped by her room last week and was in a hurry and asked her if she would want to go on the outing to watch fireworks. Resident #26 reported she told him yes and he added her name to the list and hurried off. On Friday 07/03/26, the day of the fireworks outing, Resident #26 reported she went to get on the van, and she was told by the AD #749 that her name was not on the list and she could not go. Resident #26 reported she was very disappointed especially because she found that they had stopped by the casino during the outing and even though she didn't have any money for the casino she would have liked to have gone to that also. Resident #26 reported she was still upset and disappointed about not going to the event. It was noted that the fire work show/outing was to celebrate the 250th anniversary of American Independence Day. Interview on 07/07/26 at 11:32 A.M. with the AD #749 revealed he had been with the facility for approximately two months and he was responsible for managing the activities program and developing the monthly activities calendar and events. Continued interview with AD #749 revealed the facility had a van for transporting residents to scheduled outings and that the activities department was responsible for driving the van. AD #749 reported that, if necessary, the facility would make multiple trips with the van if numerous residents wanted to attend a specific outing. AD #749 confirmed that a resident would not be told they could not attend an outing based on room for transportation and that even if one additional resident would want to go on an outing an additional trip would be made to ensure all residents who wanted to participate in the outing were able. Interview on 07/07/26 at 11:36 A.M. with the facility Administrator revealed the facility had a fourth of July celebration that included an outing for fireworks on 07/03/26. The facility had a van that could be used to take residents to and from outings and would hold up to two residents with wheelchairs, two residents without wheelchairs in the back and one additional resident in the passenger seat in the front of van for a total of five residents being able to be transported at a time. Further interview on 07/07/26 at 2:00P.M. with the AD #749 revealed that Resident #26 approached him while loading residents into the facility van for the outing to the fireworks on 07/03/26. AD #749 reported that Resident #26 asked to go to the fireworks show and he told her she could not go in what she was wearing, a night gown and slippers, and needed to go back and change her clothes. AD #749 reported, at that time, Resident #26 refused to change her clothes and was going to go in her current attire. AD #749 further reported that he did not offer to assist the Resident #26 or ask any nursing staff to assist Resident #26 with changing her clothes. AD #749 reported that he could not recall the specifics of the clothing other than it was a blue night gown looking attire and did admit there was no indecent exposure of Resident #26 in the gown. Interview on 07/07/26 at 2:13 P.M. with the activities assistant (AA) #727 revealed she was present on 07/03/26 assisting residents into the facility van for transportation to the fireworks and did recall the AD #749 talking with Resident #26 but did not hear their conversation. AA #727 further expressed that Resident #26 had a blue gown with white flowers on it that day from her recollection. AA #727 reported that Resident #26 did not get on the van and go to the fireworks but had no knowledge of why Resident #26 did not go. Review of the attendance roster for the firework outing on 07/03/26 revealed five residents signed up for the event, Residents #6, #9, #17, #32 and #36. Of those five only three residents went on the outing, Residents #6, #32, and #36. It was noted that Resident #26 was not on the list and that only three residents were on the van that had the capacity to seat up to five residents. The document was produced and verified by AD #749 who verified there was room for additional residents to board the van to go to the fireworks. 2. Review of Resident #50's medical record revealed diagnoses including Alzheimer's disease, stroke, type two diabetes, difficulty swallowing, depression, heart disease, and dementia with agitation. An initial activities assessment dated [DATE] indicated Resident #50 did not want to talk and would be assessed at a later time. The only current activity participation listed was independent activities. Everything else was marked unknown with the exception of an entry indicating Resident #50 did not wish to have visits by clergy. Review of an Activity Interview of Daily and Activity Preferences form dated 04/28/26 indicated it was somewhat important for Resident #50 to keep up with the news. Staff assessment of daily and activity preferences indicated preferences of reading materials, listening to music, and keeping up with the news. Review of a plan of care initiated 05/19/26 revealed Resident #50 had little or no activity involvement related to physical limitations. Interventions included reminding Resident #50 he could leave activities at any time. The care plan indicated Resident #50 needed a variety of activity types and locations to maintain interests. Observation of Resident #50 on 07/06/26 at 1:52 P.M., 1:54 P.M. and 4:30 P.M. revealed Resident #50's door was shut. The only interaction or stimuli noted was when a nurse responded to calling out and offered water. On 07/07/26 at 4:38 P.M., observations revealed Resident #50's door was closed and he was lying in bed with his eyes closed. No external stimulation/activity was provided. On 07/08/26 at 8:40 A.M., 10:45 A.M., 10:47 A.M., 10:48 A.M. and 10:53 A.M. Resident #50's door was closed and he was calling out. No activities were observed offered/provided. On 07/08/26 at 1:14 P.M., Resident #50's door was closed and he was lying in bed with his eyes closed with no external stimulation noted. On 07/08/26 at 5:05 P.M. Resident #50's door was shut and he occasionally moaned out. No activity or external stimulation was observed. Review of an Activity Interview of Daily and Activity Preferences form dated 07/07/26 indicated the same interests as the assessment on 04/28/26. Review of activity participation logs between 06/09/26 and 07/08/26 revealed a room visit was provided on 07/06/26. The remainder of the activity log was blank with no refusals recorded. During an interview on 07/08/26 at 10:55 A.M., Certified Nursing Assistant (CNA) #737 stated staff Resident #50 usually refused to get out of bed. Resident #50 sometimes enjoyed watching television and would ask for it to be turned on. During an interview on 07/08/26 at 2:13 P.M., Activity Director #749 stated all activity participation records were kept in the electronic health record. During an interview on 07/08/26 at 5:27 P.M., Activity Assistant #727 stated she had worked at the facility for six weeks. When she started working, she had done a couple (estimated two times) one on one visits with Resident #50. After she worked her first five days, a new activity director (Activity Director #749) started and she was not provided much direction after that. The activity department's focus was on providing transport for residents and providing activities to those residents who went to the activity room. On 07/09/26 at 7:47 A.M., the Director of Nursing (DON) provided paper activity logs for June 2026 and July 2026. Television was marked every day. The June log indicated Resident #50 had visitors and pet visits on 06/12/26 and refused newspaper on 06/13/26. One refusal of an off-site outing was recorded on 07/03/26. Interview of Activity Director #749 on 07/09/26 at 8:02 A.M., with the Administrator present, revealed he verified activity documentation was supposed to be completed in the electronic health record as previously stated. Activity Director #749 stated he was told to provide activity records so he filled out paper logs trying to rely on his memory. Activity Director #749 verified he could not confirm the records were 100% accurate. Observations and other interviews were discussed regarding the use of the television and the door being shut with every observation and if he entered Resident #50's room every day to ensure the television was on/playing. Activity Director #749 stated he has walked past Resident #50's room in the past and seen the television on.

Based on observation, medical record review, policy review and interview, the facility failed to ensure residents who smoked did so at scheduled times and in designated smoking areas. This affected one (Resident #13) of two residents screened for smoking. The facility identified 14 residents who smoked.Findings include: Review of Resident #13's medical record revealed diagnoses including type two diabetes mellitus, generalized muscle weakness, major depressive disorder, anxiety disorder and nicotine dependence. Resident #13 originally signed the smoking policy on 04/23/26. On 04/24/26, a physician's order was written indicating smoking was allowed with direct observation by staff in accordance with facility safety policy. Review of Resident #13's most recent smoking-safety screen dated 04/26/26 indicated Resident #50 required supervision and needed the facility to store the lighter and cigarettes. Smoking was allowed with direct observation by staff in accordance with the facility policy. A care plan initiated 05/01/26 indicated Resident #13 was a smoker. Interventions included instructing Resident #13 about the smoking policy including locations, times and safety concerns. Also included were instruction to notify the charge nurse immediately if it was suspected Resident #13 had violated facility smoking policy and that Resident #13 required supervision while smoking.On 07/06/26 at 8:20 A.M., Resident #13 was observed sitting in his motorized scooter smoking in the parking lot unsupervised. On 07/07/26 at 8:32 A.M., Resident #13 was observed smoking in the parking lot. Business Office Manager (BOM) #741 verified Resident #13 were smoking unsupervised. On 07/07/26 at 9:02 A.M., BOM #741 stated it was common for Resident #13 to sign out of the facility and go to the corner of the property to smoke. BOM #741 verified there was no supervision provided when Resident #13 signed out of the facility to smoke. BOM #741 verified the area where Resident #13 was observed smoking at 8:32 A.M. was on the facility grounds and did not contain a smoking receptacle.Review of Resident #13's sign out sheet revealed he had not signed out on 07/06/26.During an interview on 07/07/26 at 9:17 A.M., Licensed Practical Nurse (LPN) #734 stated Resident #13 had a history of non-compliance with the facility's smoking policy and consistently would not return his cigarettes. When Resident #13 signed out he was supposed to leave the facility grounds but she was uncertain where he went to smoke upon signing out.On 07/07/26 at 9:30 A.M., the Administrator stated residents were supposed to sign out of the facility if they were leaving to smoke if they were not going to accept supervision. However, he did not believe it was safe for residents to leave the facility's grounds. The Administrator was informed of two surveyors observing Resident #13 smoking on facility grounds outside the facility smoking times and designated smoking areas without signing out on 07/06/26. The Administrator stated he would review the smoking policy with Resident #13 again and if he remained non-compliant would have to issue a 30 day notice.Review of the facility's Smoking Policy_Residents (revised December 2016) revealed prior to, and upon admission, residents would be informed of the facility smoking policy, including designated smoking areas , and the extent to which the facility could accommodate their smoking or non-smoking preferences. Smoking was only permitted in designated smoking areas, which were located outside of the building. Smoking was only permitted during designated smoking times (listed smoking times which were updated at 9:00 A.M., 12:00 P.M., 2:30 P.M., 6:15 P.M. and 9:00 P.M.) Residents would be evaluated upon admission to determine if he or she was a smoker or non-smoker. If a smoker, the evaluation would include current level of tobacco consumption, method of tobacco consumption, desire to quit smoking and ability to smoke safely with or without supervision. The staff was to consult with the attending physician and the Director of Nursing (DON) to determine if safety restrictions needed to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. A resident's ability to smoke safely would be re-evaluated quarterly, upon a significant change and as determined by staff. Any smoking-related privileges and restrictions were to be noted on the plan of care. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, at all times while smoking. Residents were not permitted to keep cigarettes or other smoking articles in their possession. Only disposable safety lighters were permitted.

Based on observation, interview and review of drug information the facility failed to observe residents administer their respiratory inhalers and failed to ensure residents rinsed their mouth after using a steroidal inhaler. This affected one resident (Resident #10) of three residents reviewed for medication administration. |Findings include: On 07/08/26 at 8:20 A.M., Licensed Practical Nurse #715 handed Resident #10 a fluticosone furoate (Arnuity) inhaler, then turned her back to resident without observing the resident take the medication. The resident properly administered one puff of the inhaler, however she did not rinse her mouth with water following the medication administration. The LPN did not provide the resident instruction to rinse her mouth following the administration. On 07/08/26 at 8:35 A.M., an interview with LPN confirmed she did not give Resident #10 instruction to rinse her mouth following the administration of the Arnuity inhaler. She further confirmed she had turned her back on the resident and did not see her administer the medication. Review of manufacturer instructions for patient administration of Arnuity dry powder inhaler revealed after inhalation, the resident should rinse their mouth with water. The water should be spit out after rinsing and not swallowed. This is to avoid thrush (a fungal infection of the mouth).

Based on review of medical records, observations and interviews the facility failed to provide comprehensive dementia care to deter resident wandering into other resident rooms. This affected two residents (Resident #8 and #22) of two residents reviewed for abuse. The facility census was 52. Findings include: Review of the medical record for Resident #22 revealed admission to the facility on [DATE] for diagnoses including chronic respiratory failure, lung disease, malnutrition, depression, anxiety, adult failure to thrive, and anemia (low blood count).Review of the minimum data set (MDS) 3.0 quarterly assessment for Resident #22 completed on 06/10/26 revealed a brief interview for mental status (BIMS) score of 13/15 indicating Resident #22 was cognitively intact. Review of section D and E of the MDS for Resident #22 reveal no behavioral disturbances in the last 90 days. Further review of the MDS revealed Resident #22 required supervision to partial assistance with personal care, showering, and dressing. Resident #22 utilized a walker for ambulation. Review of the medical record for Resident #8 revealed admission to facility on 11/12/25 for diagnoses including Alzheimer's Dementia (progress brain disease causing memory impairment and confusion and eventual decline in functional abilities), depression, anxiety, and high blood pressure.Review of the minimum data set (MDS) 3.0 quarterly assessment for Resident #8 completed on 05/22/26 revealed a brief interview for mental status (BIMS) score of 4/15 indicating Resident #8 had severe cognitive impairment. Resident #8 was independent with walking and required no assistive device.Review of the care plan for Resident #8 revealed a care plan specific for risk of wandering and elopement with goal of resident's safety being maintained. The interventions included clearly identifying Resident's #8 room and bathroom, engaging resident in purposeful activity identifying triggers for wandering/elopement, identify wandering /elopement patterns and de-escalation behaviors, and one on one support for protective oversight. Observation on 07/06/26 at 10:15 A.M. of Resident #22's doorway revealed a netted banner with large stop sign in the middle draped across the doorway at approximately chest level, the banner was Velcro and secured to each side of the doorway for easy and quick removal.Interview on 07/06/26 at 2:11 P.M with Resident #22 revealed she recently had an interaction with Resident #8 coming into her room and attempting to get into her bed. She reported she was so upset she almost decked him. Resident #22 further reported that Resident #8 had a history of coming in her room and taking her stuff including her phone and kindle that came up missing and was later found in Resident #8's room. Resident #22 pointed to her door and stated that they put a stop sign banner over the doorway to keep him out and if he tried it again, she is going to deck him next time.Review of a nursing progress note dated 07/03/26 at 7:36 P.M. for Resident #22 revealed a male resident with dementia walked into Resident #22 room resulting in Resident #22 chasing him out of her room and shouting at him and yelling for staff to come and get him. Resident # 22 was very angry.Review of the medical record for Resident #22 revealed an order entered into the electronic medical record on 07/09/26 at 4:37 P.M. authored by the assistant director of nursing (ADON) #700 effective 06/03/26 at 7:37 P.M. to place Velcro stop sign at doorway.Review of Resident #22 thirty-day behavior log revealed no behaviors noted except on 07/03/26 when Resident #22 displayed both physical and verbal behaviors at others.Interviews on 07/09/26 between 8:45 and 8:50 A.M. with certified nursing aide (CNA) #746 and CNA #774 revealed Resident # 8 wandered the hallways a lot and requireed a lot of redirections.Interview on 07/09/26 at 8:55 A.M with licensed practical nurse (LPN) #762 revealed Resident #8 wandered the halls and was exit seeking frequently. LPN #762 further revealed that Resident #8 tended to exit seek more after returning from an outing with his family.Observation on 07/09/26 at 2:52 P.M. revealed Resident #8 wandering the hallway back and forth near Resident #22's room and looking into her room. Staff were providing verbal cues to Resident #8 to come this way toward the nurses' station when Resident #8 appeared too close to the doorway of Resident #22. Staff would also remind Resident #8 that was not his room and try to redirect him. Resident #8 would state oh, where is my room? It was noted that the Velcro stop sign was in place on the doorway during this time. It was also noted that Resident #8's room was three doors down on same side of hallway but opposite of end of the nurse's station. There was no extra signage on the door of Resident #8 room indicating it was his room other than the name tags used for all residents. Observations on 07/09/26 approximately between 3:45 P.M. revealed LPN #762 and CNA #746 were standing directly outside of Resident #22's room near walls opposite of each other monitoring area to prevent Resident #8 from entering the room. Resident #8 was finally taken back to his room by CNA #746 after several reminders not to go into Resident #22 room. The Velcro stop sign was present on the doorway.Interview on 07/09/26 at 3:45 P.M. with LPN #746 revealed Resident #8 had went into Resident #22 room again despite the stop sign and she became very angry. LPN # 746 reported she did some one on one with Resident #22 to calm her down and are standing near her door trying to prevent an incident again.Interview on 07/09/26 at 4:15 P.M. with LPN #730 revealed Resident #8's and Resident #22's behaviors had been occurring for 1-2 weeks and had to review the medical record to determine exact time that an incident occurred on 07/03/26 when Resident #8 went into Resident #22 room and she got really upset. LPN #730 further reported that Resident #8 does wander a lot and seems to be fixated on Resident #22 but they have not figured out the trigger for the behavior for the fixation of going into Resident #22's room. The LPN stated staff do one on ones with Resident #22 to get her calmed down when he does that.Interview on 07/13/26 at 8:53 A.M. with the licensed social worker (LSW) #750 revealed that in her opinion Resident # 8 should be placed in a locked memory unit which the facility does not provide. LSW #750 revealed that Resident #8 was fixated with Resident #22 and despite the stop sign being placed he still was attempting to go in her room. LSW #750 further indicated she was planning to speak with Resident # 8's wife this week about his disease progress and safety.Interview 07/13/26 at 9:17 A.M. with the Director of Nursing (DON) revealed she was only aware of one time when Resident #8 went into Resident #22 room but he did not do anything, has not had any confrontational behaviors against Resident #22. The DON stated staff put a stop sign up and Resident #22 agreed with that and there have been no further concerns. The DON did verify there was no specific signage on Resident #8's door to remind him where his room was.

Based on observation, record review, policy review and interview, the facility failed to ensure pharmacy provided medications as ordered and the discrepancy was identified prior to medication administration.This affected one resident (Resident #10) of three reviewed for medication administration. The facility census was 52.Findings include:Review of the medical record for Resident #51 revealed an admission date of 03/28/19. Diagnoses included, but were not limited to bipolar disorder, unspecified kidney failure, and dependence on renal dialysis.Review of medication orders for Resident #51 revealed an order written on 03/03/26 for Lurasidone (antipsychotic medication used to treat bipolar disorder). The order was for Lurasidone give 140 milligrams (mg) by mouth one time a day for bipolar disorder.On 07/08/2026 at 8:35 A.M., observed Lurasidone be prepared by Licensed Practical Nurse (LPN) #715 for Resident #51 to take with her to dialysis to be given at 10:00 A.M. at the dialysis center. There was only one pill in the package. Review of the medication card showed the medication was Lurasidone hydrochloride 120 mg by mouth. The instructions indicated it was to be given with Lurasidone hydrochloride 20 mg for a total of 140 mg by mouth daily. There was no 20 mg dose available in the medication cart.Review of the medical record revealed there was no order for a Lurasidone 20mg dose noted in the medical record. This was confirmed by the DON on 07/08/26 at 2:13 P.M via interview.On 07/08/26 at 2:33 P.M., a telephone interview with Pharmacist #779 from [named pharmacy] revealed when the initial order was written for Lurasidone, it had to be clarified because it did not come in 140 mg. The pharmacist clarified the order with the provider, and then sent the Lurasidone as 120 mg and 20 mg tablets. This occurred for three refills in March, April and May. When the facility requested refills on both 06/25/26 and 07/02/26, the request was sent for 140 mg, however the pharmacy had not sent any 20 mg Lurasidone hydrochloride since 05/21/26. She confirmed this was an error by the pharmacy and Resident #51 should also be getting a 20 mg tablet.On 07/08/26 at 2:50 P.M., an interview with the Director of Nursing confirmed the resident had not had the correct medication since approximately 06/25/26 when the request for a refill was processed incorrectly and the discrepancy was not identified by the administering nurses.Review of a facility policy titled Administering Medication, revised December 2012, revealed medications should be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. The person administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method of administering the medication. The individual administering the medication would initial the resident's medication administration record before administering the next medication.

Based on observation, interview and policy review, the facility failed to ensure infection control guidelines were implemented prior to the administration of an injection. This affected one resident (Resident #10) of three observed for medication administration. The facility census was 52.Findings include:Review of the medical record for Resident #10 revealed an admission date of 01/28/26. She was admitted on hospice services. Diagnoses included, but were not limited to, alcoholic cirrhosis of the liver without ascites, chronic obstructive pulmonary disease, type two diabetes mellitus with diabetic chronic kidney disease, chronic respiratory failure, and hepatic encephalopathy.Review of an quarterly Minimum Data Set (MDS) version 3.0, dated 05/14/26, revealed a Brief Interview for Mental Status (BIMS) score of seven on a 0-15 scale which would indicate the resident was moderately cognitively impaired. Review of orders for Resident #10 revealed an order for Insulin Glargine 100 units/milliliter. The resident was to receive 15 units by subcutaneous injection daily. On 07/08/26 at 10:15 A.M., an observation was made of Registered Nurse (RN) #703 administering the insulin glargine 15 units to Resident #10. RN #703 administered the injection without washing her hands and applying gloves prior to administering the medication.On 07/08/26, during an interview immediately following the medication administration, RN #703 reported she realized what she was doing as soon as she started to give the injection, but it was too late. She knew she was supposed to wear gloves before administering medications.On 07/08/26 at 10:29 A.M., Corporate Nurse #900 confirmed the expectation, and the nursing standard was to wear gloves when administering any subcutaneous injection.Review of a facility policy titled Subcutaneous Injections, revised in March 2011, revealed guidelines for the administration of medication by subcutaneous injection. After confirming all orders, the nurse was to perform hand antisepsis, apply gloves, administer the injection, and after giving the injection, remove gloves and wash and dry hands thoroughly.Review of a facility policy under the area of Infection control titled Handwashing/Hand Hygiene, revised in August 2015, revealed the facility considered hand hygiene the primary means to prevent the spread of infection. All personnel would follow the handwashing/hand hygiene procedure to help prevent the spread of infection to personnel, residents and visitors. Alcohol-based hand rub containing at least 62% alcohol or soap and water could be used before preparing or handling medications. Single use disposable gloves should be used before aseptic procedures, when anticipating contact with blood or body fluids, or when in contact with a resident, equipment or environment of a resident who was on contact precautions.

Based on observation and interview, the facility failed to ensure nursing staffing information was posted. This had the potential to affect all 51 residents.Findings include: Observations on 07/06/26 at 9:25 A.M. revealed a form posted for providing nursing staff information. The form had the date and census filled in but there was no documentation of scheduled/working hours of Registered Nurses/Licensed Practical Nurses / Certified Nursing Assistants (RN/LPN/CNAs). Dietary Manager #751 was present and verified the form was void of hours scheduled/worked.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEYBased on medical record review, interview, and Self-Reported Incident (SRI) review, the facility failed to ensure Resident #200 was free from staff to resident physical abuse when Registered Nurse (RN) #100 inappropriately treated the resident by attempting to spray holy water on the resident. This affected one resident (#200) out of one three residents reviewed for abuse. The facility census was 58.Findings Include:Review of the medical record for the Resident #200 revealed an admission date of 11/12/25 and a discharge date of 03/01/26. Diagnoses included hemiplegia, hemiparesis, aphasia following cerebral infarction, major depressive disorder, anxiety disorder, and a need for assistance with personal care. Review of Resident #200's care plan dated 11/13/25 revealed the resident had a diagnosis of depression. Interventions included education on interventions for triggers and reassurance, non-pharmacal interventions included reassurance, diversional activities, decrease stimuli, and allow the resident to vent their feelings. Attentionally the resident had a care plan related to a cerebral vascular incident (CVA/stroke). Interventions included addressing emotional issues.Review of Resident #200's quarterly Minimum Data Set assessment dated [DATE] revealed the resident had moderate cognitive impairment. The assessment also stated the resident had no physical or verbal behaviors.Review of the Self-Reported Incident #271389 dated 02/25/26 revealed the Administrator was made aware that Registered Nurse (RN) #100 asked Resident #200 if she would like her to spray holy water on her to help her feel better. Resident #200 was talking to another resident, and they were using curse words and laughing during their conversation. The nurse sprayed holy water toward Resident #200. Resident #200 didn't agree to this and was visibly bothered by this action. The nurse was suspended pending the investigation. The investigation consisted of witness statements, resident interviews with residents who had a Brief Interview of Mental Status (BIMS) score greater than 12, skin assessments for residents who had a BIMS score less than 12, and retraining of the abuse policy to all staff members. Review of Licensed Practical Nurse (LPN) #150's undated witness statement revealed Resident #200 came to her and reported that someone had sprayed her in the face with something. LPN #150 walked over to the nurse's station and asked RN #100 what happened. RN #100 admitted she sprayed Resident #200 with holy water due to her using the Lord's name in [NAME]. LPN #150 assessed the resident for injuries. Review of RN #100's witness statement dated 02/25/26 revealed on 02/24/26 around 11:00 P.M. two residents were swearing loudly, using an explicit word alongside the name of Jesus. They were reminded to be quieter because it was late. When Resident #200 started to insult the Lord, RN #100 reported to the resident that it hurt her because she was consecrated to the Lord. The resident continued and RN #100 told Resident #200 that she had holy water and that perhaps (the holy water) would help her to be nicer. It was a [NAME] bottle that the nurse had on herself and used on herself often. The nurse then spritzed twice in the direction of the resident from about six feet away. RN #100 reported Resident #200 became very agitated and whipped herself into an emotional state. She was red-faced, pointing, swearing, and continuing to threaten the safety of the nurse.Interview on 04/09/26 at 3:25 P.M. with Regional Director of Clinical Services #153 reported the nurse was terminated related to customer service after the incident. She verified RN #100 did not provide appropriate behavioral intervention related to the incident with Resident #200.The deficiency was corrected on 02/25/26 after the facility implemented the following corrective actions: -On 02/24/26, Resident #200 was assessed for injuries and no injuries were noted. The Medical Director was made aware and an investigation was initiated.-On 02/24/26 RN #100 was removed from the facility and was terminated on 02/25/26 due to poor customer service related to this incident. -On 02/25/26 all residents with a BIMS of 12 or higher were interviewed by the nursing delegates to ensure no further abuse concerns. -On 02/25/26 all residents with a BIMS lower than 12 received skin assessments by the nursing delegates.-On 02/25/26 staff members who were working on 02/24/26 were interviewed by the Administrator regarding the incident with RN #100 and Resident #200. There was one witness identified as LPN #150. -On 02/25/26 the Administrator conducted abuse training for all staff members.-On 02/25/26 the Administrator/designee continued to complete already implemented ongoing guardian angel/adopt a resident monitoring (a program where a nurse manager goes in daily and visits with residents about care needs and if they feel abuse, neglected, and respected) with residents Monday through Friday. The rounds continued daily with Resident #200 until her date of discharge on [DATE]. The results of the audits would be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.-On 02/26/26 an ad hoc QAPI meeting was held with department leadership to discuss the incident, the education that was conducted, and how imposing ones religious beliefs could be considered allegations of abuse or violations of residents rights.

Based on observation, interview, review of hospital notes, review of consents, and medical record review, the facility failed to implement appropriate interventions and supervision to ensure Resident #2 did not leave the facility without supervision and engage in unsafe behaviors. This affected one resident (#2) out of three residents reviewed for safety interventions. The facility's census was 58.Findings Include:Review of Resident #2's Substance Use Disorder Program consent dated 03/11/26 completed prior to admission to the facility, revealed the objective was to initiate a quality of care program designed to standardize substance use disorder care throughout the facilities for improved outcomes, provide education to the residents affected and staff for continuity of care, decrease potential relapse of Substance Use Disorder and Infection resolution, and provide safety measures for the residents and reduce liability for the facilities. The insight into compliance and effectiveness of the program will be obtained by: Monitoring compliance with PICC line tampering and assessment by the nursing staff if implemented, monitoring mandatory counseling sessions, monitor urine drug screens as needed for compliance with the program, monitor rate of discharge for non-compliance with the Stepping Stones and substance use disorder program, random room searches, random drug screens, and automatic discharge from facility if not following rules: All visitations must occur between the hours of 9:00 A.M. and 5:00 P.M.; All visits will be supervised; Random search of any delivered packages; And no leave of absence (LOA) unless agreed in collaboration with Stepping Stones Counselor, Interdisciplinary Team (IDT), and Physician on a case-by-case basis.Review of Resident #2's hospital discharge paperwork dated 03/23/26 completed prior to admission to the facility, revealed the resident tested positive for amphetamines and cannabinoids. The resident presented to the hospital with bilateral lower extremity pain. He was found to have osteomyelitis of his right third toe and left second toe. He underwent amputation of both toes. He was placed on intravenous (IV) antibiotics and discharged with a peripherally inserted central catheter (PICC) line. Review of the medical record for Resident #2 revealed a facility admission date of 3/24/26. Diagnoses included bipolar disorder, alcohol abuse, anxiety disorder, other psychoactive substance abuse disorder, atrial fibrillation, and acquired absence of the left toe. The resident was his own responsible party. Review of Resident #2's elopement assessment dated [DATE] revealed he was at a low risk.Review of Resident #2's care plan dated 03/25/26 revealed the resident had a substance abuse disorder. Interventions included that residents would attend all group and individual stepping stone activities during stay, will complete all homework group and individual assignments, and will follow the Stepping Stones protocol.Review of Resident #2's skin assessment dated [DATE] revealed the resident a surgical wound to his right foot measuring 2.3 centimeters (cm) length, by 0.1 cm width, and 0.1 cm depth. Review of Resident #2's admission Minimum Data Set 3.0 assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) of 15 indicating his cognition was intact. Review of Resident #2's Functional Abilities and Goal assessment dated [DATE] revealed the residents' lower extremities had an impairment on both sides and he utilized a wheelchair or scooter.Review of the LOA sign out sheet revealed Resident #2 signed out at 04/02/26 at 3:38 P.M. and back in at 9:40 P.M.Review of the nursing progress note dated 04/02/26 at 2:00 P.M. but created on 04/03/26 at 1:21 P.M. by Assistant Director of Nursing (ADON) #157 revealed she was informed by staff the resident had signed himself out. There was confusion as to if he was picking up Chinese food, getting belongings, etc., Staff were asked where he was going, and they were told to notify her (ADON #157) upon his return, and to notify the medical director. The resident had a BIMS of 15, and the LOA book was observed at this time and the resident had signed himself out. Review of the facility investigation revealed on 04/02/26, Resident #2 discussed with staff throughout the day he was going LOA but did not give a time. Around 4:00 P.M., the resident left LOA to get his personal items via a friend's car. At 5:08 P.M., the local police department called and reported someone escaped from the facility. Staff reported Resident #2 was noted to be on LOA to get items. Police asked if the resident was safe and the facility reported yes, he was his own person, and alert and oriented times three. At 5:30 P.M., Resident #2's friend came into the facility and brought personal items stating that the resident was coming with his [motorized wheel] chair. At 7:27 P.M., the facility received a text from Licensed Practical Nurse (LPN) #156 stating Resident #2 was on the sidewalk in the community wearing a hat, boots, black shorts, a grey shirt and a hospital gown. At 8:00 P.M., the resident called the facility stating that he was at a local tavern charging his [wheel] chair. At 9:32 P.M., the facility was notified that the resident was in the parking lot heading into the facility and the provider was made aware. At 9:47 P.M., staff noted Resident #2 signed back into the facility. A skin sweep and head to toe assessment was completed without abnormal findings.Observation and interview on 04/08/26 at 10:30 A.M. of Resident #2 revealed he was wearing a surgical boot to his right foot, had a PICC line to his right arm, his gait was slightly unsteady, and he had a large, motorized wheelchair in his room. Resident #2 revealed his sister picked him up on 04/02/26 to pick up his motorized wheelchair. He reported he signed out LOA but did not report to staff he was leaving. He reported he knew he was not supposed to leave unsupervised due to conversations he had previously with administration but due to the opportunity to get his chair he decided to leave anyway. He stated once he got to the apartment where his chair was at, he had to ride it back to the facility. He stated he talked to the facility and told them what was going on and asked to be picked up. They reported to him that they were not going to pick him up. He stated he had to stop at several locations on the way home to charge his chair. He stated it was approximately five miles he had to travel. He stated he also pushed the chair part of the way home. He reported when he got back, they gave him his medication and assessed him for injury. Interview on 04/08/26 at 2:21 P.M. with Certified Nursing Assistant (CNA) #151 reported she was Resident #2's CNA on 04/02/26. She was aware he planned to leave to get his wheelchair, but was not sure of a time. She did not believe he had privileges to leave and he did not report to her when he left the facility. She reported that LPN #156 was aware that he was planning to leave. Interview on 04/08/26 at 3:08 P.M., admission Director #152 stated Resident #2 tested positive for amphetamines during his prior hospitalization (before facility admission) and was admitted on the Stepping Stones program, and he had to sign the Stepping Stones consent to be admitted to the facility. They were in between counselors so there were not any meetings going on. She had talked to him, and he was aware he was not allowed to leave the facility without supervision. She went on to say he did not report to anyone before he left, but once they were aware he had left, she was able to communicate with him via his cell phone. He had expressed concerns about needing his motorized wheelchair since his admission but no one at the facility had gotten it for him and no one had dropped it off for him. She reported the Administrator told him that if he could find a way, then he could get it, so his sister and a friend came in and picked him up. admission Director #152 reported to the Administrator after he left asking if we [indicating the facility staff] could pick him up with his chair so he wouldn't be riding it back to the facility, but the Administrator stated she was not going to. admission Director #152 reported he had to ride it back on the highway and stopped at a random person's house, a fast-food restaurant, and a tavern to charge his chair. He arrived back at 9:30 P.M. Interview on 04/08/28 at 3:40 P.M., the Administrator stated facility staff made her aware that Resident #2 had left without reporting to anyone but did sign the LOA book. She confirmed was aware he was riding his wheelchair back but did not offer to pick him up, stating by the time she made it to the facility he would already be making his way back. She went on to say that the facility no longer offered the Stepping Stones program, so he did not have any restrictions in place. Interview on 04/08/26 3:50 P.M., Regional Director of Clinical Services #153 reported Resident #2 was recently admitted with the intention to be on the Substance Abuse Disorder Program [Stepping Stones] but since they did not have a counselor available, he was never actually placed on the program. She reported the facility did not assess his needs for additional supervision or add interventions due to his high cognition. She verified at this time his care plan stated he was to follow the Stepping Stones protocol and he did sign the consent for the safety interventions. She stated once he returned, he was educated on safety precautions and needed to report to someone if he was leaving the facility. Interview on 04/08/26 at 4:20 P.M. with Physician #155 reported that if Resident #2 was leaving without supervision he would have preferred for him to sign out Against Medical Advice (AMA) due to the risk related to having a PICC line. Interview on 04/09/26 at 1:23 P.M., LPN #156 reported he was Residents #2's nurse on 04/02/26. He stated the resident didn't specifically come to him and report he was leaving. He had previously been talking about having a power chair since his admission and how if he didn't get it, someone else would sell it. He was really focused on this power chair and the day he left he was mentioning the power chair a little more than usual. He overheard a conversation where the resident was trying to pinpoint where it was. He was pretty sure the resident was going to leave that day. LPN #156 stated he was not sure how the resident got the LOA book to sign out, but thinks that he must have gone behind the desk to get it himself. LPN #156 reported he was told the resident was on the Stepping Stones program and had limited access to LOAs. He reported once he realized Resident #2 signed out LOA, he let Assistant Director of Nursing (ADON) #157 know around 4:00 P.M. and LPN #156 reported when he left the facility, Resident #2's picture was already on social media, and he was able to pass him on the way home. He stated he had regular clothing on and a hospital gown over his clothing. He reported he sent a picture to the ADON.Interview on 04/09/26 at 2:50 P.M., ADON/Wound Nurse #157 reported around 3:30 P.M. Resident #2 left the facility by signing out but did not verbally tell anyone. She advised staff to call the Physician upon his return to the facility. She went on to say the local police department called and asked if he was safe. She reported that he signed himself out LOA, had a BIMS of 15, and was alert and oriented. At 6:15 P.M., the resident's sister called and reported the resident was riding his chair back to the facility. She stated she did not offer to provide transportation back to the facility and stated he arrived back around 9:30 P.M. and he received a skin assessment and drug test which he passed. This deficiency represents an example of continued non-compliance investigated under Complaint Number 2973326.

Based on observation, interview, review of hospital paperwork, review of Substance Use Disorder Program consent, review of the facility investigation, and record review, the facility failed to ensure residents received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for substances abuse. This affected one resident (#2) out of three residents reviewed for safety interventions. The facility's census was 58.Findings Include: Review of Resident #2's Substance Use Disorder Program consent dated 03/11/26 completed prior to admission to the facility, revealed the objective was to initiate a quality of care program designed to standardize substance use disorder care throughout the facilities for improved outcomes, provide education to the residents affected and staff for continuity of care, decrease potential relapse of Substance Use Disorder and Infection resolution, and provide safety measures for the residents and reduce liability for the facilities. The insight into compliance and effectiveness of the program will be obtained by: Monitoring compliance with PICC line tampering and assessment by the nursing staff if implemented, monitoring mandatory counseling sessions, monitor urine drug screens as needed for compliance with the program, monitor rate of discharge for non-compliance with the Stepping Stones and substance use disorder program, random room searches, random drug screens, and automatic discharge from facility if not following rules: All visitations must occur between the hours of 9:00 A.M. and 5:00 P.M.; All visits will be supervised; Random search of any delivered packages; And no leave of absence (LOA) unless agreed in collaboration with Stepping Stones Counselor, Interdisciplinary Team (IDT), and Physician on a case-by-case basis. Review of Resident #2's hospital discharge paperwork dated 03/23/26 completed prior to admission to the facility, revealed the resident tested positive for amphetamines and cannabinoids. The resident presented to the hospital with bilateral lower extremity pain. He was found to have osteomyelitis of his right third toe and left second toe. He underwent amputation of both toes. He was placed on intravenous (IV) antibiotics and discharged with a peripherally inserted central catheter (PICC) line. Review of the medical record for Resident #2 revealed a facility admission date of 3/24/26. Diagnoses included bipolar disorder, alcohol abuse, anxiety disorder, other psychoactive substance abuse disorder, atrial fibrillation, and acquired absence of the left toe. The resident was his own responsible party. Review of Resident #2's admission Minimum Data Set 3.0 assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) of 15 indicating his cognition was intact. Review of Resident #2's care plan dated 03/25/26 revealed the resident had a substance abuse disorder. Interventions included that residents would attend all group and individual stepping stone activities during stay, will complete all homework group and individual assignments, and will follow the Stepping Stones protocol. Review of the medical record revealed no documented evidence that Resident #2 was receiving Stepping Stones activities, assignments, homework, or follow ups with a counselor.Review of the LOA sign out sheet revealed Resident #2 signed out at 04/02/26 at 3:38 P.M. and back in at 9:40 P.M.Review of the nursing progress note dated 04/02/26 at 2:00 P.M. but created on 04/03/26 at 1:21 P.M. by Assistant Director of Nursing (ADON) #157 revealed she was informed by staff the resident had signed himself out. There was confusion as to if he was picking up Chinese food, getting belongings, etc., Staff were asked where he was going, and they were told to notify her (ADON #157) upon his return, and to notify the medical director. The resident had a BIMS of 15, and the LOA book was observed at this time and the resident had signed himself out. Review of the facility investigation revealed on 04/02/26, Resident #2 discussed with staff throughout the day he was going LOA but did not give a time. Around 4:00 P.M., the resident left LOA to get his personal items via a friend's car. At 5:08 P.M., the local police department called and reported someone escaped from the facility. Staff reported Resident #2 was noted to be on LOA to get items. Police asked if the resident was safe and the facility reported yes, he was his own person, and alert and oriented times three. At 5:30 P.M., Resident #2's friend came into the facility and brought personal items stating that the resident was coming with his [motorized wheel] chair. At 7:27 P.M., the facility received a text from Licensed Practical Nurse (LPN) #156 stating Resident #2 was on the sidewalk in the community wearing a hat, boots, black shorts, a grey shirt and a hospital gown. At 8:00 P.M., the resident called the facility stating that he was at a local tavern charging his [wheel] chair. At 9:32 P.M., the facility was notified that the resident was in the parking lot heading into the facility and the provider was made aware. At 9:47 P.M., staff noted Resident #2 signed back into the facility. A skin sweep and head to toe assessment was completed without abnormal findings.Interview on 04/08/26 at 2:21 P.M. with Certified Nursing Assistant (CNA) #151 reported she was Resident #2's CNA on 04/02/26. She was aware he planned to leave to get his wheelchair, but was not sure of a time. She did not believe he had privileges to leave and he did not report to her when he left the facility. She reported that LPN #156 was aware that he was planning to leave. Interview on 04/08/26 at 3:08 P.M., admission Director #152 stated Resident #2 tested positive for amphetamines during his prior hospitalization (before facility admission) and was admitted on the Stepping Stones program, and he had to sign the Stepping Stones consent to be admitted to the facility. They were in between counselors so there were not any meetings going on. She had talked to him, and he was aware he was not allowed to leave the facility without supervision. She went on to say he did not report to anyone before he left, but once they were aware he had left, she was able to communicate with him via his cell phone. He had expressed concerns about needing his motorized wheelchair since his admission but no one at the facility had gotten it for him and no one had dropped it off for him. She reported the Administrator told him that if he could find a way, then he could get it, so his sister and a friend came in and picked him up. admission Director #152 reported to the Administrator after he left asking if we [indicating the facility staff] could pick him up with his chair so he wouldn't be riding it back to the facility, but the Administrator stated she was not going to. admission Director #152 reported he had to ride it back on the highway and stopped at a random person's house, a fast-food restaurant, and a tavern to charge his chair. He arrived back at 9:30 P.M. Interview on 04/08/28 at 3:40 P.M., the Administrator stated the facility no longer offered the Stepping Stones program so he did not have any restrictions in place. Interview on 04/08/26 3:50 P.M., Regional Director of Clinical Services #153 reported Resident #2 was recently admitted with the intention to be on the Substance Abuse Disorder Program [Stepping Stones] but since they did not have a counselor available, he was never actually placed on the program. She reported the facility did not assess his needs for additional supervision or add interventions due to his high cognition. She verified at this time his care plan stated he was to follow the Stepping Stones protocol and he did sign the consent for the safety interventions. She stated once he returned, he was educated on safety precautions and needed to report to someone if he was leaving the facility. Interview on 04/08/26 at 4:10 P.M., Social Service Director #154 reported the facility was offering a Substance Abuse Program that they did not actually have. She reported the facility had not had a counselor in several months. She reported she had been at the facility since September 2025 and they had never had a therapist and no one was doing weekly check ins on the residents who were in the program.Interview on 04/08/26 at 4:20 P.M. with Physician #155 reported he was made aware the facility did not have a substance abuse program on 04/07/26. Interview on 04/08/26 at 10:30 A.M. with Resident #2 revealed he was admitted on a Substance Abuse Program and knew he wasn't allowed to leave the facility. He reported and confirmed that he had not received any services related to the program yet.Interview on 04/09/26 at 1:23 P.M., LPN #156 reported he was Residents #2's nurse on 04/02/26. He stated the resident didn't specifically come to him and report he was leaving. He had previously been talking about having a power chair since his admission and how if he didn't get it, someone else would sell it. He was really focused on this power chair and the day he left he was mentioning the power chair a little more than usual. He overheard a conversation where the resident was trying to pinpoint where it was. He was pretty sure the resident was going to leave that day. LPN #156 stated he was not sure how the resident got the LOA book to sign out, but thinks that he must have gone behind the desk to get it himself. LPN #156 reported he was told the resident was on the Stepping Stones program and had limited access to LOAs. He reported once he realized Resident #2 signed out LOA, he let Assistant Director of Nursing (ADON) #157 know around 4:00 P.M. and LPN #156 reported when he left the facility, Resident #2's picture was already on social media, and he was able to pass him on the way home. He stated he had regular clothing on and a hospital gown over his clothing. He reported he sent a picture to the ADON.Observation on 04/09/26 at 1:35 P.M. of Residents #2 revealed he was upset, unable to keep his head up, and smelled of alcohol. Interview on 04/09/26 at 1:40 P.M., Regional Director of Clinical Services #153 reported Residents #2 went to appointment earlier today where he received bad news. Once he returned, he decided to leave for the store. He did not sign out or tell anyone he was leaving. Interview on 04/09/26 at 2:33 P.M., Transporter #158 reported they arrived back at the facility around 12:00 P.M. today. The resident stated he did not want to come back to the facility. She told the resident to talk to the nurse and see if he could sign himself out. She reported he followed her into the facility, and she assumed he went to talk to the nurse. Interview on 04/09/26 at 3:00 P.M. Activity Director #159 heard that Resident #2 was at a local grocery store. She drove to the store to speak with him. Once she arrived, she noticed the resident had a bottle of alcohol. He willingly gave her the bottle, and she noticed some had spilled on him. She was able to convivence him to come back to the facility. She is unsure of how much he drank, or if any. Interview on 04/09/26 at 3:25 P.M., Regional Director of Clinical Services #153 reported Resident #2 left the facility today after his doctor's appointment without notifying staff. He was found at the local grocery store with alcohol. He was transported back to the facility where he wanted to sign out Against Medical Advice (AMA) and then made comments about self-harm. He then was pink slipped to the emergency room. Regional Director of Clinical Services #153 confirmed there were no policies, procedures, or admission information for the Stepping Stones program other than the consent form.

Based on observation, interview, record review, review of the Facility Assessment, and review of the facility's admission agreement, the facility failed to provide sufficient nursing staff was available to ensure resident safety and effectively care for residents. This had the potential to affect all residents residing in the facility. The facility census was 65.Findings include: 1.Review of the closed medical record for Resident #73 revealed an admission date of 02/20/26 with medical diagnoses including peritoneal abscess, anemia, and a history of substance abuse. Resident #73 discharged from the facility against medical advice (AMA) on 02/27/26.Review of a progress note dated 02/27/26 at 10:05 P.M. revealed Resident #73 informed the nurse that she wanted to sign out against medical advice. Resident #73 was educated on the risks of leaving AMA and was informed she could not leave the facility with a peripherally inserted central catheter (PICC) line in. The PICC line was removed by the Registered Nurse on duty by utilizing sterile technique. Pressure was applied to the cite and a pressure dressing was applied. The physician was notified of Resident #73 signing out AMA and Resident #73's boyfriend arrived to take the resident out of the facility. Interview on 03/04/26 at 1:49 P.M. with CNA #77 revealed on 02/27/26, two nurses (LPN #01 and RN #20) walked out of the building and there were no nurses in the facility. Following both nurses' leaving, there were no nurses in the facility until LPN #423 showed up to the building around 5:00 P.M. Prior to LPN #423 arriving, residents were asking for help and assistance and requesting medications, but there were no nurses there to assist them.Interview on 03/04/26 at 3:14 P.M. with Certified Nursing Assistant (CNA) #230 revealed on 02/27/26 there was approximately one hour when there were no nurses in the building after Licensed Practical Nurse (LPN) #01 and Registered Nurse (RN) #20 left the facility at approximately 3:30 P.M. Administrator #95 began making phone calls to get another nurse in the building. CNA #230 recalled during the time where no nurses were in the building, Resident #73 requested multiple times for her intravenous tubing to be removed from her arm, but there was not a nurse present to do so. Interview on 03/09/26 at 11:49 A.M. with Medical Records Staff #50 revealed on 02/27/26, RN #20 walked out of the building. LPN #01 then approached Medical Records Staff #50 and asked if she had keys to the medication room, and LPN #01 replied that's where my keys will be. Medical Records Staff #50 reported she walked out of the building with LPN #01 and assumed LPN #01 had relief because, at the time, LPN #01 was the only nurse in the building. Upon her return to the building, Medical Records Staff #50 realized there were no nurses in the building that anyone was aware of. At that time, approximately 3:30 P.M. (on 02/27/26), there were no nurses in the building and only CNAs on the floor. Around 5:00 P.M., LPN #423 arrived. Interview on 03/09/26 at 11:53 A.M. with LPN #423 revealed on 02/27/26, there were no nurses in the building for a period after LPN #01 and RN #20, who were the two nurses working that day, walked out of the facility at approximately 3:30 P.M. LPN #423 reported she received a call to see if she could come to work and arrived approximately 40 minutes later and clocked in on 02/27/26 at 5:03 P.M. LPN #423 reported she did not get report from anyone, no nurses were in the building when she arrived, and about ten minutes after she arrived at the facility, additional nurses arrived and she completed a narcotic count with the arriving nurses.Interview on 03/09/26 at 3:40 P.M. with LPN #01 revealed on 02/27/26, she left the facility directly after RN #20. LPN #01 confirmed she left the keys to the medication cart in the medication room and made Administrator #95 aware she was leaving. LPN #01 reported the DON and ADON had quit the week before, so there were no other nurses in the building and no one to give a handoff report to or complete a narcotic count with. LPN #01 reported on 02/27/26, LPN #01was the only one passing medications as RN #20 did not have proper access to the facility's electronic health record system. Medications scheduled for 8:00 A.M. were administered late. There were nearly 70 residents in the facility and one nurse (LPN #01) trying to pass all medications. LPN #01 reported a new admission came, and during the day one unit would go up to three hours without a nurse on the unit, but LPN #01 could not be in two places at once. LPN #01 reported it was a nightmare. A telephone interview on 03/10/26 at 2:54 P.M. with Resident #73 revealed she left AMA from the facility as there was never any help in the facility. Resident #73 reported her medications were often late. Resident #73 reported on 02/27/26, she had asked two (unnamed) CNAs to get a nurse to remove her intravenous antibiotic from her PICC line, and no one came. Finally, Resident #73 stated she walked into the hallway with the antibiotic hanging from her arm to find a nurse to remove it. Resident #73 stated she could not find any nurses in the facility at all. Resident #73 recalled feeling like no one cared, which led her to a breaking point and to signing out of the facility AMA later that day.2. The following additional concerns were identified during the onsite complaint investigation:a. Interview on 03/04/26 at 7:26 A.M. with CNA #70 revealed staffing had been rough. Typically, CNA #70 reported they would work with two aides to care for nearly 40 residents. CNA #70 reported residents were not getting quality or timely care completed, including showers. CNA #70 reported the staffing on the night shift (from 11:00 P.M. to 7:00 A.M.) was terrible, with only one aide on the south end of the building and one aide on the north end of the buildings; two aides to care for approximately 70 residents. b. Interview on 03/04/26 at 8:20 A.M. with CNA #105 revealed staffing was not sufficient to meet the needs of the residents. CNA #105 reported staff would not have time to complete showers and would have to hope the next shift was able to complete showers. CNA #105 further explained if care tasks were able to be completed, many times charting was incomplete because staff did not have time to document the care they provided in a timely manner.c. Interview on 03/04/26 at 9:36 A.M. with CNA #42 revealed staffing was very short, especially for CNAs. CNA #42 reported staff would routinely get behind which led to a delay in resident care, such as incontinence care, showers, and medications being provided to residents. The issue affected everyone and residents became frustrated. CNA #42 reported resident call lights could take over 30 minutes for staff to be available to answer the call light, and sometimes residents could wait even longer if two staff members were required for certain care activities. d. Interview on 03/04/26 at 2:57 P.M. with LPN #527 revealed the staffing in the facility was not sufficient. LPN #527 reported when she would enter her shift, residents would be soaked (due to incontinence) because there was only one aide on each side of the building on the overnight shift. LPN #527 stated it was impossible to care for almost 70 residents when their care needs included toileting and incontinence care, dressing, passing medications and treatments, passing and collecting trays, and assisting with feeding. LPN #527 reported everything from resident care to medication administration was late, the staff could not take breaks, and this was negatively affecting the staff and residents and causing staff call offs and burn out.e. Interview on 03/04/26 at 6:21 P.M. with LPN #76 revealed staffing at the facility was horrible. Night shift struggled the most, they were extremely short staffed with a high census and high acuity residents. The facility continued to admit new residents without adequate staff on all shifts to care for them. LPN #76 reported there were currently multiple geriatric psychiatric residents, one of which required 1:1 with a staff member for a history of sexually aggressive behavior towards staff. LPN #76 reported there were other residents with frequent falls, and others who required a lot of attention and oversight for being fall and elopement risks. LPN #76 reported medications and treatments were always late due to lack of staff, and depending on the unit, staff could have up to 50 residents to provide care for. LPN #76 reported the insufficient staffing was causing a lot of staff turnover because staff were burned out, were unable to take breaks, leaving the facility hours after their shift officially ended, and were calling off. LPN #76 reported staff were collectively frustrated because they were unable to provide quality and timely care for residents. Residents were constantly requesting care but were told they had to wait, sometimes for hours, because there were no staff available to assist.f. Interview on 03/05/26 at 7:50 A.M. with LPN #100 revealed the facility was unable to adequately staff the building to meet the needs of the residents. LPN #100 explained that the facility had several geriatric psychiatric admissions with a lot of behaviors, screaming, and some who have had sexually aggressive behaviors towards staff members. Night shift had the lowest staffing levels, with two nurses and two CNAs in the building on the night shift. LPN #100 reported it was nearly impossible to run with this staffing level due to the needs of the residents. Nurses would try to assist the CNAs, but then medication and treatment administrations would be late. LPN #100 stated several residents required two staff members for assistance with transferring using a mechanical lift. When CNAs take residents into the shower, it would leave one CNA to care for the remaining residents of the facility. LPN #100 reported staff at times had trouble juggling the needs and demands of the residents including answering call lights, providing toileting and/or incontinence assistance, and administering medications and treatments, and sometimes these care tasks were delayed due to insufficient staff. LPN #100 noted if a new admission would arrive during a busy time, the nurse may be unavailable for other residents while they tended to the new admission. LPN #100 reiterated there was no admission nurse (to assist with completing new resident admission tasks) and no Assistant Director of Nursing (ADON) or Director of Nursing (DON) to assist with completing required tasks. g. Interview on 03/05/26 at 8:56 A.M. with Human Resource Staff #51 reported they completed the schedule for the nursing and CNA staff members. Human Resource Staff #51 reported there had been some chaos with staff leaving, and the night shift schedules for both nurses and CNAs had been difficult to fill. Human Resource Staff #51 reported the facility had recently started utilizing agency staff to attempt to fill open holes.h. Interview on 03/05/26 at 9:26 A.M. with Resident #36 revealed there were not enough staff, and the facility was short-handed. There were not enough staff to supervise the residents. Other residents would wander into her room, and she would have to re-direct them. Resident #36 reported Resident #39 would wander into rooms a lot, but the resident was confused and did not know what was going on. Resident #36 reported on another day, an unspecified resident wandered into her room and took her slippers, and she had to ask for them to give them back herself.i. Interview on 03/05/26 at 10:26 A.M. with CNA #73 revealed staffing at the facility was horrible. Some shifts there were only two CNAs in the whole building. Residents had not been able to go down to the dining room because of the lack of staff. Resident rooms were unkempt with garbage left in the rooms. CNA #73 reported residents would be soiled and their care delayed because of lack of staff. CNA #73 reported residents would complain about cold food because staff were not able to pass trays timely to all residents of the facility. Residents had begun to get frustrated and would start yelling at staff for not getting assistance timely. CNA #73 reported they tried not to tell the residents it was due to short staffing, but residents were anxious due to wait and the lack of help.j. Interview on 03/05/26 at 11:01 A.M. with Resident #61 revealed the facility did not have enough staff. There were usually two CNAs working on each (north and south) hall. Resident #61 reported she was more independent and did not need as much help as her roommate, Resident #49. Resident #61 reported staff was visible frustrated and recalled an incident on an unknown date when an unknown staff member was putting Resident #49 to bed and stated, I am tired of this [expletive]!. Resident #61 reported some residents end up staying in bed most or all day because there were not enough staff to get them up.k. Interview on 03/05/26 at 11:10 A.M. with Resident #54 reported medications and help were late, but staff could only do so much with the short staffing. Resident #54 reported the call button takes a long time to be answered by staff, but she understood they were busy. Resident #54 reported staff do not stay (employed at the facility, staff retention was low). Resident #54 reported a few weeks ago, she had reported a bad migraine to the ADON at the time. The ADON stated she would be back but did not come back with any medication. Resident #54 stated she pushed her call light two additional times, but no one came. Resident #54 stated she just had to deal with it (the migraine) and placed a cool washcloth on her head. Resident #54 reported there were days when there was no nurse on her side of the building because they had to go to the other side to assist with something. Resident #54 noted there was only one aide at each end of the building at night, which was not enough.l. Interview on 03/05/26 at 11:26 A.M. with LPN #90 revealed staffing was severely insufficient. There was only one nurse on north and one nurse on south side, and one nurse could have over 40 residents with one or two CNAs each. Medications were always in the red (indicating medications were past the scheduled time for administration). Residents were not receiving timely or quality care, and the staffing levels were being normalized by the facility. The nurses and CNAs were constantly having to stay hours past the scheduled ends of their shifts to complete an admission or to continue caring for residents due to call offs. m. Interview on 03/06/26 at 1:45 P.M with Resident #09 revealed the facility did not have enough nurses or CNAs. If the call light was pressed (activated), it took about half an hour for the call light to be answered. Resident #09 reported if ice water was requested, one could wait another 20 minutes or more before the staff member returned. Resident #09 reported she was worried about residents who could not speak for themselves and who did not know what was happening. Resident #09 reported night shift had hardly any staff and recalled a night where it took her 45 minutes to get water. Resident #09 reported the staff who were working that night was good, but there were only two aides for the whole building, and they were going back and forth from the north to the south end to help each other. The nurses were short-handed as well, medications are not brought on time or consistently, but she recognized there were other residents in the facility to care for, as well as emergencies and issues that arose.n. Interview on 03/09/26 at 8:50 A.M. with LPN #720 revealed their third day of orientation was supposed to be scheduled on 03/06/26. Upon arrival for her orientation shift at the facility, she found she was working independently on the north end of the facility by herself, with no one to orient her. LPN #720 reported she had not worked on or been trained on that unit before.o. Interview on 03/09/26 at 12:32 P.M. with Resident Representative #800 revealed there were not enough staff working at the facility. Resident Representative #800 stated they were very concerned with the afternoon and night shift staffing as there were not enough staff to assist all the residents.p. Interview on 03/09/26 at 3:54 P.M. with Resident #07 revealed the facility needed more people working. The residents do not get enough help. Resident #07 reported that sometimes there is only one CNA working on each end of the building. Resident #07 reported she had to wait a long time for help and recalled there had been times she had been stuck on the toilet waiting for staff to return. Resident #07 reported she had continued to sit on the toilet to wait for staff even though it hurt her buttocks as she was fearful of falling. Resident #07 reported the wait times were longer on evening and night shifts.Review of the undated facility admission agreement revealed the facility agrees to provide the patient with 24-hour nursing care in a manner and setting appropriate to the patients' needs. Review of the facility admission packet revealed basic services included in the daily rate include twenty-four hour per day nursing care, assistance and/or supervision when required with activities of daily living, including but not limited to, toileting, bathing, feeding and ambulation assistance. Review of the Facility assessment dated [DATE] revealed the purpose of the assessment was to determine what resources were necessary to care for the residents competently during both day-to-day operations and emergencies. The facility must utilize the facility assessment to inform staffing decisions to ensure that there are enough staff with the appropriate competencies and skill sets necessary to care for the residents' needs as identified through resident assessments and plans of care, consider specific staffing needs such as day, evening, and night shifts with adjustments as necessary based on the population, develop and maintain a plant o maximize recruitment and retention of direct care staff, and inform contingency planning for events that do not require activation of the facility's emergency plan but that do have the potential to affect resident care, such as, but not limited to: the availability of direct care nurse staffing or other resources as needed for resident care. The assessment noted that a full time DON, ADON, MDS Nurse, and part-time Wound Care nurse were needed, but the assessment did not identify any information about how many licensed nurses (including RNs and LPNs) were needed to care for the resident population, nor were there provided details about recruitment or contingency plans.This deficiency represents non-compliance investigated under Master Complaint Number 2794699 and Complaint Numbers 2785803 and 2747771.

Based on observation, interview, and record review, the facility failed to ensure the services of a Registered Nurse (RN) were provided for at least eight consecutive hours a day, seven days a week. Additionally, the facility failed to ensure a full time Director of Nursing (DON) was employed and actively working within the facility. This had the potential to affect all residents residing in the facility. The facility census was 65. Findings include: Review of the Facility Assessment completed 01/30/26 revealed the facility must have a full-time DON, a full-time ADON, a full-time wound care nurse, and full-time Minimum Data Set (MDS) nurse.Review of staff clock in times and resident record review in times revealed no documentation of a Registered Nurse being in the building for eight consecutive hours on 02/21/26 or 03/08/26.Interview on 03/04/26 at 8:08 A.M. with Certified Nursing Assistant (CNA) #103 revealed there was no Director of Nursing (DON) or Assistant Director of Nursing (ADON) in the facility. CNA #103 further explained there was no one management nursing-wise to report issues or concerns to and reiterated there was no DON, no ADON, no Minimum Data Set (MDS) nurse, nor a wound care nurse working within the facility.Interview on 03/04/26 at 8:10 A.M. with CNA #801 revealed there was no DON or ADON working within the facility that they were aware of. CNA #801 reported the turnover was bad in the facility and the DON and ADONs come and go. CNA #801 reported there was no communication between floor staff and management and provided an example that new admissions just show up.Interview on 03/05/26 at 8:56 A.M. with Human Resource Staff #51 revealed the previous DON gave a thirty-day notice with an intended final day of work on 03/13/26. On 02/19/26, the former DON stated she was not working out her notice and did not return. On 02/21/26, the previous ADON gave a notice that they were resigning effective immediately. Currently, positions for an MDS nurse, wound care nurse, and ADON are open. Human Resource Staff #51 reported the facility recently hired a DON whose first day of work is planned for 03/16/26.Interview on 03/05/26 at 3:35 P.M. with Licensed Practical Nurse (LPN) #01 revealed the facility is short on Registered Nurse (RN) hours. The facility will schedule an RN, but they call off, don't show up, or quit. Names will appear on the schedule, but bodies are not in the building. LPN #01 reported it had gotten worse with no ADON or DON in the building.Interview on 03/10/26 at 4:22 P.M. with CNA #199 revealed the facility had been without a Director of Nursing for a little while. The previous DON and ADON both quit on the same day. CNA #199 reported no one came to the facility to fill in and stated no corporate nurses were physically in the building to fill in for the DON or ADON. Interview on 03/11/26 at 12:01 P.M. with Anonymous Staff Member #999 confirmed the facility is not meeting the required RN hours. The facility will put RN names on the schedule or the patient per day (PPD) sheets, but no one is physically in the building. The facility has told staff that a new DON had been in on certain days, but no one knows who they are or if they are even in the building. Anonymous Staff Member #999 reported the corporate nurses had not come in to assist the facility staff. This deficiency represents non-compliance investigated under Master Complaint Number 2794699 and Complaint Numbers 2785803 and 2747771.

Based on record review, interview and policy review the facility failed to ensure medications were administered per physician orders. This affected one resident (Resident #73) of five residents reviewed for medication administration. The census was 65. Finding Include: Record review revealed Resident #73 admitted to the facility on [DATE] with diagnoses including abscess of the spleen, chronic viral hepatitis C, and peritoneal abscess.Review of Resident #73's physician orders revealed an order for Cubicin Intravenous (IV) solution reconstituted 500 milligrams (mg) (Daptomycin), give 350 mg IV one time a day at 9:30 A.M. for abdominal abscess until 03/24/26. Further review revealed the resident had a peripherally inserted central catheter (PICC)/ midline (left arm) with orders to monitor for leaking and/ or signs and symptoms of infection every shift.Review of Resident #73 care plan revealed no documentation, goals, or interventions for the resident's intravenous medication therapy related to an active infection, and maintenance, use, or observation of the residents Peripherally Inserted Central Catheter (PICC).Review of Resident #73 medication administration record revealed Cubicin 350 mg IV reconstituted 500 mg daptomycin was scheduled on 02/27/26 at 9:30 A.M.Further review of Resident #73's medication administration record revealed the medication was not administered until 02/27/26 at 3:20 P.M. (six hours late) by Licensed Practical Nurse (LPN) #01.Interview on 03/05/26 at 3:35 P.M. with LPN #01 revealed on 02/27/26, she was the only nurse to administer medications to nearly 70 residents and medications were administered late this day, including Resident #73's Cubicin.Interview on 03/10/26 at 1:50 P.M. with Regional Director of Clinical Operations #106 confirmed on 02/27/26 Resident #73's IV antibiotic, Cubicin 350 mg IV reconstituted 500 mg daptomycin was documented as being administered by LPN #01 at 3:20 P.M., six hours late.Review of facility policy titled medication therapy revised April of 2007 revealed each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. Facility shall review medication related issues as part of its quality assurance committee and activities. This deficiency represents non-compliance investigated under Master Complaint Number 2794699.

Based on interview, and record review, the facility failed to ensure residents received appropriate supervision and intervention to prevent leaving the facility unsupervised. This affected one resident (Resident #55) of two residents reviewed for accidents. The census was 65.Findings include: Resident # 55 admitted to the facility on [DATE] with diagnoses including dementia type two diabetes, hypertension, anxiety, major depressive disorder, and neurocognitive disorder with Lewy bodies.Review of Resident #55's Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03 indicating severe cognitive impairment. The resident utilized a wheelchair and required moderate assistance for transfers and mobility. Review of Resident #55 assessment for elopement review completed on 01/07/26 revealed the resident scored a 10 on the assessment indicating they were a high risk for elopement.Review of Resident #55 care plan revealed a plan of care initiated on 02/13/26 for Resident #55 was an elopement risk/wanderer related to disoriented to place, a history of attempts to leave the facility unattended, and impaired safety awareness. Goals include the resident's safety being maintained. Interventions include distracting the resident from wandering by offering pleasant, diversion, structured activities, food, conversation, television, and books. Identify a pattern of wandering: divert as needed and intervene as appropriate. If resident exhibits signs of exit seeking and/or verbalizes wanting to leave, then initiate 1:1 supervision. Monitor for fatigue and weight loss. Provide activity of interest to deter from wandering. Provide supervision for off-unit activities.Review of Resident #55 progress note dated 03/07/26 at 4:30 P.M. revealed a note authored by Licensed Practical Nurse (LPN) #88 which stated a resident put on their call light and an aide responded. The aide came out and told staff the resident saw another resident by himself outside, sitting on the sidewalk in the parking lot of the facility in the rain. The aides and LPN #88 assisted Resident #55 back into the building. The Medical Director (MD) was notified by LPN #49 and gave a new order for a wanderguard (a wearable bracelet-like device used to monitor and prevent residents at risk for wandering from leaving designated areas; it is part of a larger system which includes sensors on doors which alarm and lock doors when a resident approaches a monitored exit) to be placed.Interview on 03/09/26 at 12:32 P.M. with Resident Representative #800 revealed on 03/07/26, Resident #55 walked out of the door, in the rain, by himself. No one saw him leave, and no one knows how he got there. Resident representative #800 stated they did not think Resident #55 could walk, so they're unsure how he got outside. It was another resident who saw Resident #55 sitting in the parking lot on a parking stop, that resident then called or told a staff member there was a resident outside by themselves in the rain.Interview on 03/09/26 at 12:45 P.M. with Resident #09 revealed Resident #09 was watching TV on 03/07/26 and noticed a man sitting on the parking stop in the parking lot. Resident #09 stated it looked like the man was playing in the water as it was raining outside. Then, Resident #09 realized it was a resident sitting outside. Once she realized it was a resident, Resident #09 pressed her call light and told a (unnamed) Certified Nursing Assistant (CNA) there was a resident in the parking lot.Interview on 03/09/26 at 1:58 P.M. with CNA #68 revealed on 03/07/26 they were working, it was raining at that time. CNA #53 answered Resident #09's call light and came back and alerted staff that Resident #55 was outside sitting in the parking lot. Resident #55's wheelchair was still inside the facility. CNA #68 stated they are unsure how Resident #55 had the strength to push open the doors and walk outside. CNA #68 and CNA #53 went outside to assist Resident #55 back into his wheelchair and back into the facility. CNA #68 stated they had seen Resident #55 attempt to stand, but he usually sits back in his wheelchair; CNA #68 had never seen Resident #55 walk that far. CNA #68 stated Resident #55 does have exit seeking and wandering behaviors and the resident is usually sat at the nurse's station and if he wanders, they will bring him back.Interview on 03/09/26 at 2:16 P.M. with CNA #53 revealed on 03/07/26, Resident #09's call light came on, so CNA #53 went to answer it. Resident #09 stated there was someone outside. CNA #53 looked outside and realized it was Resident #55 sitting in the parking lot, outside, in the rain. CNA #53 stated they have never seen Resident #55 walk, but he had tried to in the past but had fallen. CNA #53 and CNA #68 went outside to assist in getting Resident #55 back inside the building.Interview on 03/10/26 at 8:03 A.M. with Administrator #95 confirmed Resident #55 was found by another resident, who alerted staff, of Resident #55 being outside in the facility parking lot by himself. Administrator #95 revealed there were cameras in the facility, but they did not have a recording from 03/07/26 showing Resident #55 exiting the facility.Interview on 03/10/26 at 2:49 P.M. with Regional Director of Clinical Operations (RDCO) #106 confirmed Resident #55 was found on 03/07/26 outside of the facility in the parking lot, and staff was made aware Resident #55 had left the building by Resident #09.Review of facility policy titled wandering, unsafe resident revised 10/13/2020 revealed the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement or other risk due to judgement or cognition. Policy interpretation and implementation include the staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). The staff will assess at risk individuals for potentially correctable risk factors related to unsafe wandering. Residents who are at risk may have a secure care or other such bracelet device placed for additional security prevention. The resident care plan will indicate the resident is at risk for allotment or other safety issues and interventions will try to maintain safety such as detailed monitoring plan, wanderguard, etcetera will be included. And then saying resident is considered a facility wide emergency if a resident is missing, the elopement / missing resident emergency procedure will be initiated.Review of the policy Wandering, Unsafe Resident dated 10/13/20 revealed the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement or other risk due to judgement or cognition. The policy noted staff will identify residents who are at risk for harm because of unsafe wandering and will assess residents for potentially correctable risk factors related to unsafe wandering. The resident's care plan will indicate the resident is a risk for elopement or other safety issues. Interventions will try to maintain safety, such as a detailed monitoring plan, Wanderguard, etc. A missing resident is considered a facility-wide emergency. If a resident is missing, the elopement/missing resident emergency procedure will be initiated. This deficiency represents non-compliance investigated under Master Complaint Number 2794699 and Complaint Numbers 2785803 and 2747771.

Based on observation, staff interview, and record review, the facility failed to ensure Resident #49 was served food in mechanically altered form to meet her needs. This affected one resident (#49) of three residents reviewed for appropriate diets. The facility identified 13 residents who were identified by the facility to require a mechanically altered diet. The facility census was 65.Findings include:Review of the medical record for Resident #49 revealed an admission date of 09/26/25 with diagnoses including Alzheimer's disease and hypertension. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #49 was identified to be dependent on staff for eating . Resident #49 required a mechanically altered diet. Review of the undated list of residents requiring a mechanically altered diets, provided by the facility, revealed Resident #49 required a mechanical soft diet. Interview on 03/05/26 at 10:26 A.M. with Certified Nursing Assistant (CNA) #73 revealed mechanical soft food should be small, but the kitchen was just cutting the foot up in large pieces. Telephone interview on 03/09/26 at 2:08 P.M. with CNA #777 revealed the kitchen staff provided regular food to residents who required a mechanical soft diet, including Resident #49. Observation on 03/09/26 at 5:00 P.M. of Resident #49's meal tray revealed a meal ticket arrived with Resident #49's supper tray. The ticket noted Resident #49 was on a mechanical soft diet. Continued observation of Resident #49's meal tray revealed on the tray was a hamburger that was cut up in large pieces and placed on a hamburger bun. Interview on 03/09/26 at 5:00 P.M. with CNA #777 at the time of observation confirmed Resident #49 had an order for a mechanical soft diet. CNA #777 confirmed the hamburger cut up into large pieces on a full-size bun was not appropriate on a mechanical soft diet. CNA #777 confirmed the hamburger in large pieces on the resident's tray would not be safe for Resident #49 to consume. This deficiency represents noncompliance investigated under Complaint Number 2785803.

Based on medical record review, hospital record review, review of data found at www.kidneyfoundation.org, policy review and interviews, the facility failed to prevent an incident of neglect when Resident #51 did not receive hemodialysis treatments as ordered due to a lack of facility provided transportation. This resulted in Immediate Jeopardy and actual harm with risk of death beginning on 07/21/25 when Resident #51, who was dependent on hemodialysis due to end stage renal disease, was not transported to a scheduled dialysis treatment. The resident subsequently missed hemodialysis on 07/23/25 again due to a lack of facility provided/arranged transportation. As a result, Resident #51 developed symptoms of fluid volume overload, shortness of breath, fatigue and weakness. The facility failed to timely identify the resident's condition change and did not transfer the resident to the emergency room (ER) until the evening of 07/23/25 at which time she was diagnosed with hyperkalemia (elevated potassium level of 7.7 (critical)) due to missed hemodialysis treatments and required admission to the intensive care unit (ICU) to receive continuous renal replacement therapy (CRRT) to restore the resident's blood potassium level and prevent imminent deterioration of the resident's condition. This affected one resident (Resident #51) of one resident identified by the facility to receive hemodialysis treatments. The facility census was 52. On 08/04/25 at 4:47 P.M. the Director of Nursing #7, Assistant Director of Nursing #6, Administrator #128 , Regional Director of Operations (RDO) #614, and Regional Director of Clinical Services 615 were notified Immediate Jeopardy began on 07/21/25 when the facility failed to secure transportation for Resident #51 to receive life sustaining hemodialysis treatments required due to the resident's end stage renal disease. Due to the missed appointments, the resident was hospitalized in the intensive care unit requiring continuous renal replacement. The resident was assessed to have hyperkalemia, was hyponatremic and her electrocardiogram revealed cardiac changes, including heart block, due to the changes in condition associated with the missed hemodialysis treatments. The Immediate Jeopardy was removed on 08/04/2025 when the facility implemented the following corrective actions: On 08/04/2025 from 5:07 P.M. until 5:17 P.M. Regional Director of Operations (RDO) #614 Regional Director of Clinical Services #615, Administrator #128, Director of Nursing (DON) #7 and Assistant Director of Nursing (ADON) #6 were educated via Teams call by VP of Clinical Operations #613 and VPO #612 regarding: Abuse and Neglect Policy, Resident examination and assessment, Change in Resident's Condition or Status with Notification, Transportation and interventions, and Charting and Documentation. On 08/04/2025 at 5:20 P.M. all department heads were educated via in-person meeting by RDO #614 and Regional Director of Clinical Services #615 on Abuse and Neglect Policy, Resident examination and assessment, Change in Resident's Condition or Status with Notification, Transportation and interventions, and Charting and Documentation. Department heads educated included Administrator #128, DON #7, Business Office Manager (BOM) #129, ADON #6, admission Coordinator/Marketing #218, Dietary Manager #65, Social Services #106, Minimal Data Set (MDS) Registered Nurse (RN) #2, Regional Director of Clinical Services #615, RDO #614, and Central Supply/Medical Records #5. On 08/04/2025 from 5:30 P.M. until 6:00 P.M. an audit of the facility appointment calendar was completed for all 52 residents for missed appointments due to transportation concerns the week of 07/21/2025 to 07/28/2025 when the facility was without a wheelchair accessible van. Two additional residents were identified as having missed appointments and were clinically assessed for a decline in condition. The audit completed by ADON #6 identified Resident #15 had a chemotherapy appointment scheduled for 07/21/2025 but arranged transportation did not arrive to transport the resident on 7/21/2025. Resident #15's appointment was rescheduled for 07/31/2025 and transportation was provided by the facility. Resident #17 had a non-life sustaining dermatology appointment scheduled for 07/21/2025. Transportation was canceled by Valley Logistics transportation company; the Activity Director was notified on 7/18/2025 when the Activity Director called to confirm transportation arrangements. This appointment and transportation were rescheduled to 08/18/2025, with the facility to transport. On 08/04/2025 from 6:04 P.M. until 6:40 P.M. resident interviews were conducted to identify possible situations of neglect. Thirty-one (31) residents with a Brief Interview for Mental Status (BIMS) score of 13 or higher were interviewed by the BOM. Residents interviewed included Resident #4, # 5, #10, #11, #12, #13, #14, #15, #17, #18, #19, #20, #21, # 22, #23, #26, #28, #29, # 32, #34, #35, #37, #38, #42, #43, #47, # 48, #50, #51, #53, and #55. Questions included, Has staff, a resident or anyone else here neglected you? and Have you seen any resident here being neglected?. On 08/04/2025 from 6:05 P.M. until 6:40 P.M. resident skin assessments were completed for (21) residents with a BIMS score of 12 or lower by facility ADON #6 and DON #7. Residents assessed included Resident #1, #2, #3, #6, # 7, #8, #9, #16, #27, #30, #31, #33, #36, #39, #40, #41, #45, #46, #49 and#54. On 08/04/2025 from 6:40 P.M. until 7:00 P.M. a Quality Assurance Performance Improvement (QAPI) meeting was held meeting held with facility staff members including Administrator #128, Director of Nursing #7, BOM #129, Assistant Director of Nursing #6 , admission Coordinator/Marketing #218, Dietary Manager #65, Social Services #106 (by phone), MDS RN #2, Regional Director of Clinical Services #615, Regional Director Operations #614, Central Supply/Medical Records #5, and Medical Director #606 (by phone). The QAPI agenda consisted of the review of the facility IJ abatement plan, a root cause analysis, staff education topics, and weekly audits to be completed. The root cause was identified as transportation concerns arose, staff did not complete appropriate notifications, assessments, and interventions to ensure Resident #51 had no adverse effects. Education topics include pertinent facility policies, including the policies titled, Abuse and Neglect Policy, Resident examination and assessment, Change in Resident's Condition or Status with Notification, Transportation and interventions, and Charting and Documentation. On 08/04/2025 from 6:59 P.M. until 8:44 P.M. an audit of the facility EHR report titled 72 Hour Report, which included weights and vitals, progress notes, the completion of assessments, etc. for the previous 72 hours, was completed for all 52 residents by MDS RN #2, to confirm appropriate notifications and interventions for residents with a change in condition. On 08/04/2025 from 7:05 P.M. until 7:17 P.M. All Staff Education was completed remotely by RDO #614 via facility communication system on the topics of Abuse/ Neglect, Resident examination and assessment, Change in Resident's Condition or Status with notification, Transportation and interventions, and Charting and Documentation. All 80 staff members were educated, including re-education to facility administration. (Education was provided to 20 licensed practical nurses (LPN) and registered nurses (RN), 34 Certified Nursing Assistants (CNAs), eight dietary staff members, six housekeeping staff members, one laundry staff member, two activity staff members, one central supply/medical records staff member, and eight administrative staff members. The facility communication system allowed facility administration to send information to staff via Short Message Service (SMS), with confirmation of receipt of the message being received by the facility for each staff member. In addition to the remote education, facility staff were to sign an in-service sheet in acknowledgement of receipt of this education, at the arrival of the facility for their next scheduled shift. This was being audited daily by facility Administrator or Designee, until completion. The facility's new hire orientation was updated by the facility Administrator to include the policies outlined in the completed education. On 08/04/2025 from 8:00 P.M. until 8:19 P.M. all appointments scheduled for 07/27/25 through 08/02/25 were audited for missed appointments due to lack of transportation by DON #7. Residents who had appointments included Resident #51, Resident #43, Resident #50, Resident #15. On 08/04/25 from 8:13 P.M. until 8:28 P.M. all appointments scheduled for Sunday 08/03/25 through 08/09/25 were audited to ensure transportation was scheduled. The audit was completed by BOM #129. Residents who have scheduled appointments included Resident #51, Resident #3, Resident #36, Resident #37, Resident #20. Transportation would be completed by the facility or Valley Logistics transportation company for all appointments. On 08/04/25 at 10:39 P.M. Resident #51's care plan was updated to add appropriate steps for any missed dialysis appointments per facility policies by MDS RN #2. Resident #51's care plan would be accessible to nursing staff via facility Electronic Health Record (EHR), including transportation interventions and notification, in accordance with facility policies titled, Transportation, Charting and Documentation, and Change in a Resident's Condition or Status, Resident Examination and Assessment, and a handout titled Education Highlights. The facility implemented a plan for the following audits to be initiated on or by 08/06/2025: o Appointment calendar will be audited for accuracy, completion and transportation five times per week for four weeks and then weekly for four weeks by DON or designee. The facility appointment calendar is managed by Activity Director, including the verification of scheduled appointments and transportation. All transportation is completed by the facility and/or Valley Logistics transportation company. o Interventions for missed appointments would be audited by DON or designee five times per week for four weeks then weekly for four weeks, including documentation in the medical record of interventions and notifications to facility DON and primary care provider team. Facility EHR bulletin board notice posted on 08/04/2025 at 10:46 P.M. by RDO #614 for nurses to notify DON of any missed appointments. o 24/72hr report to be reviewed for resident changes in condition would be audited daily Monday through Friday; Monday to capture Friday through Sunday five times per week for four weeks to ensure proper documentation is included such as assessments, adverse reactions, unusual occurrences, refusals, declines, notifications. Audit to be completed by DON or Designee. o Resident interviews for residents with a BIMS of 13 or higher or head to toe assessments for residents with a BIMS of 12 or lower to assess for concerns of neglect would be completed for three random residents five times per week for four weeks and then three random residents weekly for four weeks by DON or Designee. o Results of all audits would be reviewed weekly, at minimum, by the facility's QAPI committee for the duration of the audits. Although the Immediate Jeopardy was removed on 08/04/2025 the deficiency remains at Severity Level II (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include:Record review revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including respiratory failure, type two diabetes, chronic obstructive respiratory disease, anemia, atherosclerotic heart disease, schizophrenia, borderline personality disorder, hypothyroidism, hypertension, chronic kidney disease, kidney failure and renal (hemo)dialysis dependence. Review of Resident #51's physician orders revealed an order for hemodialysis every Monday, Wednesday, and Friday at an outside dialysis center due to renal failure. Review of Resident #51's care plan dated 04/11/25 revealed the resident needed hemodialysis related to renal failure. Goals included the resident would have immediate intervention should any signs or symptoms of complications from dialysis exist. The care plan reflected the resident received (hemo)dialysis at (name and location of dialysis center) on Monday, Wednesday, and Friday at 10:30 A.M. Interventions included encouraging the resident to go for their scheduled dialysis appointments. Monitor vital signs and notify the medical doctor (MD) of significant abnormalities. Monitor, document, report as needed (PRN) for signs and symptoms of renal insufficiency such as changes in level of consciousness, changes in skin turgor, oral mucosa, and changes in heart and lung sounds. Check arteriovenous (AV) fistula (a connection between an artery and vein surgically created to receive dialysis) site thrill (a palpable vibration or tremor felt over an AV fistula that indicates turbulent blood flow)/bruit (an abnormal sound, often described as a swishing or blowing that can be heard with a stethoscope over a blood vessel and indicates turbulent blood flow); palpate/feel to assess for thrill and auscultate for bruit as ordered. Review of Resident #51 quarterly Minimum Data Set (MDS) assessment completed 06/04/25 revealed the resident had a BIMS score of 15 (out of a total score of 15), indicating Resident #51 was cognitively intact. The assessment also reflected the resident received dialysis. Review of Resident #51's dialysis communication binder, taken to and from each dialysis appointment for communication between the facility and the dialysis provider, revealed Resident #51 did not receive dialysis treatments on 07/21/25, or 07/23/25. Resident #51 last attended a dialysis appointment was on 07/18/25 which resulted in Resident #51 going a total of five days without being dialyzed before she was transferred to the hospital (on 07/23/25) for emergent medical intervention/treatment. Further reviews of Resident #51's medical record revealed no documentation, including vital signs, were available on 07/21/25 or 07/23/25 until the resident was transported to the hospital for evaluation (on 07/23/25). Further review revealed no additional nursing progress notes or documentation the resident missed the hemodialysis treatments on this date. There was no documentation the resident's physician or nephrologist were notified of the missed hemodialysis treatments. Review of Resident #51's progress note dated 07/23/25 at 6:49 P.M. authored by Registered Nurse (RN) #120 revealed Resident #51 was feeling very weak and having a change in condition, sending to emergency department for evaluation. An additional note dated 07/23/25 authored by LPN #38 at 10:48 P.M. revealed the resident was admitted to the hospital. Review of Resident #51's emergency room documentation dated 07/23/25 and authored by Doctor of Medicine (MD) #608 revealed Resident #51 presented to the emergency department (ED) on 07/23/25 from a skilled nursing facility (SNF) with shortness of breath. Resident #51 had a past medical history (PMH) of end stage renal disease (ESRD) and missed dialysis on Monday 07/21/25 due to lack of transportation from the SNF. Lab work revealing hyperkalemia, potassium 7.7 milliequivalents per liter (mEq/L) (normal range 3.5-5.0 mEq/L), mixed metabolic and respiratory acidosis (a serious life-threatening situation when the lungs and the body's metabolism are making the blood too acidic at the same time, caused by an increase in carbon dioxide and an excessive amount of acid build up). Electrocardiogram (EKG) showing Intraventricular conduction delay (IVCD) (the electrical signals from the lower heart chambers are moving slower than usual, causing the heart to beat out of sync or rhythm therefore not pumping blood to the body efficiently). Resident #51 was admitted to the ICU to facilitate continuous renal replacement therapy (CRRT). CRRT is a type of dialysis that provides a continuous, 24-hour treatment with acute kidney injury who are too unstable for traditional, intermittent dialysis methods offering life-saving support to critically ill patients. Primary hospital diagnoses for Resident #51 hospital admission from 07/23/25 through 07/25/25 included acute hyperkalemia, encounter for CRRT for end-stage renal disease (ESRD) and admitted to intensive care unit (ICU) for CRRT. Resident #51 required CRRT, transitioning to hemodialysis (HD), hyperkalemia treatment, strict intake and outputs, serial basic metabolic panel (BMP) lab work, and hyponatremia improving with CRRT. Hyponatremia (lab work revealing sodium of 128) was likely due to volume overload with two missed hemodialysis (HD) sessions. EKG on admission with sinus bradycardia (a slower than normal heart rate, less than 60 beats per minute) , second degree atrioventricular (AV) block (a heart rhythm where electrical signals from the upper chambers of the heart are not conducted to the hearts lower chambers causing the heart to miss a beat) , Mobitz type 2 right bundle branch block (the right side of the heart has a delay in receiving electrical signals causing signals to come late or be completely missed), repeat EKG showing sinus bradycardia with sinus arrhythmia and right bundle branch block, likely metabolic in nature secondary to missed HD and hyperkalemia. Patient was treated with medications without significant improvement and was admitted to ICU for dialysis.Review of Resident #51's hospital record revealed an EKG reading from 07/23/25 authored by Cardiologist #609 that stated Resident #51 had junctional bradycardia with intermittent heart block, widening of the QRS complex, this was a change when compared to prior EKGs Review of Resident #51's hospital record revealed an admission note authored by MD #606 which included Resident #51 was dialysis dependent (for renal failure) and she missed (HD treatments) due to transportation issues. EKG showed junctional bradycardia with intermittent heart block, widening of the QRS complex. Resident #51 showed hyperkalemic changes on her EKG, changes that were not there on the previous. Resident #51 would be admitted to the ICU for dialysis. Review of Resident #51's hospital record revealed a hospital admission note dated 07/23/25 and authored by the emergency department physician Doctor of Osteopathic Medicine (DO) #610, which documented Resident #51 had a high probability of imminent life or limb threatening deterioration due to severe hyperkalemia with EKG changes. Review of Resident #51 hospital record revealed a note dated 07/24/25 and authored by Nephrologist #611 which included Resident #51 was known to their practice due to her dialytic needs. Resident #51 was typically compliant with her treatments for dialysis. Resident #51 missed dialysis on Monday 07/21/25 and Wednesday 07/23/25 due to the nursing facility not having transportation because of issues with their van. Lab work revealed hyperkalemia, acidemia, and cardiac involvement secondary to hyperkalemia. The note included will touch base with our team regarding further management from her facility so these transportation issues are resolved. Review of Resident #51's progress note dated 07/25/25 at 7:42 P.M. and authored by LPN #304 revealed Resident #51 returned from the hospital after admission for continuous dialysis. Interview on 07/30/25 at 10:34 A.M. with offsite Dialysis Registered Nurse (RN) #604 revealed it was not recommended for any patient who required dialysis to miss an appointment for dialysis. Missing even just one appointment could lead to hospitalization and possible death. Someone who may be presenting with adverse reactions from missing dialysis could include confusion and diarrhea; the resident's potassium level could rise causing hyperkalemia; a dangerous excess amount of potassium leading to cardiac changes. Interview on 07/30/25 at 10:59 A.M. with offsite dialysis social worker, Licenses Social Worker (LSW) #603 revealed on Monday 07/21/25 the facility called the dialysis center to cancel Resident #51's dialysis appointment due to transportation issues. LSW #603 also shared the facility canceled dialysis on 07/23/25, without reason. At that time (on 07/23/25) dialysis staff recommended the resident be sent to the ER. Further interview revealed Nephrologist #611 shared, later on 07/23/25, that Resident #51 was in the hospital requiring continuous renal replacement therapy (CRRT). Nephrologist #611 wanted to discharge Resident #51 from the hospital on [DATE] back to the facility; however, the facility advised against this stating they felt it was safer for the resident to remain in the hospital for dialysis. Resident #51 was scheduled for dialysis on 07/25/25 at the offsite dialysis center but remained in the hospital at that time. LSW #603 stated missing a dialysis appointment could lead to toxin build up and fluid overload, some symptoms may include shortness of breath, nausea and vomiting, and swelling. Interview with Via [NAME] Therapeutic Behavior support (TBS) #605 on 07/30/21 at 1:20 P.M. revealed she saw Resident #51 a few days a week. TBS #605 revealed Resident #51 missed a few dialysis appointments and was in the hospital the week of 07/21/25 to 07/25/25. TBS stated she was told Resident #51 missed dialysis due to transportation issues; transportation was down. TBS #605 stated she was told this on Wednesday 07/23/25. TBS #605 stated she went in to see Resident #51on 07/23/25 around 2:30 P.M. and Resident #51 said she didn't feel good and that she had thrown up. TBS #605 shared Resident #51 was not her usual self that day. TBS #605 stated she notified the nurse but could not remember which nurse. TBS #605 shared the nurse said they were aware and told her Resident #51 hadn't been feeling well. Interview with Registered Nurse (RN) #11 on 07/30/25 at 2:51 P.M. confirmed Resident #51 did not receive hemodialysis on 07/21/25 and 07/23/25 on her usual appointment days due to the facility not having transportation to get Resident #51 to the dialysis facility. Interview on 07/30/25 at 3:10 P.M. with LPN #60 verified Resident #51 missed two hemodialysis appointments, on Monday 07/21/25 and Wednesday 07/23/25. The LPN revealed Resident #51 missed her dialysis appointments due to not having transportation to the dialysis center and back. LPN #60 stated Resident #51 was ready for dialysis and as time passed and it got closer to when she would usually leave, someone then told them there was no transportation and dialysis was cancelled. LPN #60 stated Resident #51 was eventually transferred to the hospital due to a status change, not feeling well and not acting like her usual self. The nurse stated the resident was in the ICU for a few days due to missing two dialysis appointments. During that time Resident #51 required an ICU admission for CRRT. Interview on 07/30/25 at 3:23 P.M. with Licensed Practical Nurse (LPN) #200 confirmed on 07/21/25 Resident #51 missed her dialysis appointment. LPN #200 stated Resident #51's dialysis appointment was missed due to the facility not having a van to transfer the resident to and from dialysis on 07/21/25. Interview on 07/30/25 at 3:54 P.M. with Anonymous Staff Member (ASM) #484 revealed Resident #51 was not acting herself on Wednesday 07/23/25. The ASM stated Resident #51 had missed two dialysis appointments due to transportation issues and was not acting herself, she would answer appropriately but was acting off. Before Resident #51 was transferred to the hospital, she had vomited. ASM #484 revealed at times when Resident #51 didn't feel good she could be more agitated than usual, maybe a little crabby at times when she was unwell but Resident #51 wasn't even doing this, it was as if the lights were on but no one was there. ASM #484 confirmed Resident #51 was transferred to the emergency room on [DATE] because of her change in status. Interview on 07/30/25 at 4:07 P.M. with Certified Nursing Assistant (CNA) #377 revealed the week of 07/20/25 through 07/26/25 the facility's transportation van was down and out of order. CNA #377 confirmed Resident #51 missed two dialysis appointments due to having no transportation to get there. CNA #377 revealed the days leading up to Resident #51 being transferred to the hospital Resident #51 was not herself, she was acting different than she usually did and even stated several times she was feeling sick. Interview on 07/30/25 at 4:24 P.M. with LPN #61 revealed transportation had been down since last week (week of 07/20/25). LPN #61 revealed residents were missing appointments due to this. LPN #61 stated Resident #51 did not go to dialysis on 07/21/25 due to having no transportation and the resident appeared more tired than usual the days following up to her being admitted to the ICU (on 07/23/25). The LPN was unsure if Resident #51's physician or nephrologist were notified of the resident missing her dialysis appointments. LPN #61 denied any knowledge of anyone trying to set up alternative transportation for Resident #51 for the dialysis on Monday or Wednesday; the transportation vehicle was down so her appointments got canceled. Interview on 07/30/25 at 4:54 P.M. with Resident #51 confirmed she missed dialysis on Monday 07/21/25 because there was no van but stated she could not recall if she missed dialysis on Wednesday 07/23/25 due to her not being able to remember anything from those days. Resident #51 stated she didn't remember if she had dialysis or not, she didn't remember if she was sick, she did not remember if she felt unwell, she couldn't recall anything from those days. Resident #51 shared she missed dialysis on Monday and then she woke up and was in the hospital, in the ICU with a lot of stuff going on around her. Resident #51 stated anything between the two events she didn't recall. Resident #51 stated to her knowledge the dialysis center called the facility to see where she was and that was when the facility told dialysis that she wouldn't be making it to dialysis because the van wasn't working. Resident #51 stated she does not believe her doctor knew she wasn't going to dialysis. Resident #51 stated she knows what goes on, she doesn't forget things, however she stated she could not remember anything after missing dialysis on 07/21/25 until she woke up in the ICU. Interview on 07/30/25 at 6:02 P.M. with ASM #455 revealed Resident #51 missed two dialysis appointments on 07/21/25 and 07/23/25. ASM #455 stated these appointments were missed due to the facility transportation van being out of order. The ASM stated to their knowledge no one attempted to get alternative transportation for Resident #51 to get to her dialysis appointments for either of the two appointments missed. ASM #455 revealed on the days leading up to Resident #51 hospital admission (on 07/23/25) the resident was not right at all, she was acting different, complaints of not feeling well, and even her body color was not what it usually was. ASM #455 revealed something should have been done sooner, transport was down Monday, but the resident still missed Wednesday; and it seemed like her status was worsening and nothing was being done about it. Interview on 07/31/25 at 7:14 A.M. with CNA #74 revealed Resident #51 missed two dialysis appointments on 07/21/25 and 07/23/25. CNA #74 confirmed that these two dialysis appointments were missed due to the facility transportation van being broke down. An interview on 07/31/25 at 7:30 A.M. with CNA #301 revealed on 07/21/25 Resident #51 was up and ready for her dialysis appointment like she was every Monday. Around 9:30 A.M. they were notified that there was no transportation for Resident #51 to go to dialysis. Resident #51 then missed another dialysis appointment on 07/23/25 again due to having no transportation. This resulted in Resident #51 being admitted to the hospital in the intensive care unit requiring continuous dialysis. Interview on 07/31/25 at 7:55 A.M. with CNA #64 confirmed Resident #51 missed two dialysis appointments on Monday 07/21/25 and Wednesday 07/23/25. CNA #64 stated these dialysis appointments were missed due to the facility transportation vehicle not working. CNA #51 confirmed Resident #51 ended up in the intensive care unit requiring continuous dialysis due to missing the two appointments. Interview on 07/31/25 at 8:31 A.M. with CNA #21 confirmed Resident #51 missed dialysis appointments due to not having transportation to get there. CNA #21 revealed awareness of Resident #51 missing dialysis on 07/21/25 and stated she was unsure of how many more days she missed. CNA #21 revealed Resident #51 in the days leading up to her hospitalization after missing dialysis complained of being short of breath, but she was unsure if that was correlated. Interview on 07/31/25 at 12:59 P.M. with facility medical director (MD) #606 revealed the MD was not notified of Resident #51 missing dialysis on 07/21/25 or 07/23/25. MD #606 stated when Resident #51 was admitted to the hospital (on 07/23/25) he was notified she was being admitted , but it wasn't until after that that he was told she had missed two dialysis days. MD #606 revealed missing a dialysis day could result in fluid overload, hyperkalemia, hospitalization, myocardial infarction (MI), and even death. Some symptoms you would experience with fluid overload or hyperkalemia included shortness of breath, cardiac changes, and vomiting. Interview on 07/31/25 at 11:27 A.M. with ASM #450 revealed Resident #51 missed two dialysis appointments, one on 07/21/25 and the other on 07/23/25. The ASM voiced they felt the facility was negligent with Resident #51 missing her dialysis appointments and facility's lack of reaction to Resident #51 decline leading up to her hospitalization. ASM #450 revealed the facility transport van had been down for a while and they (the facility) had ample time to get transportation set up, the facility rented a van to take residents to a wrestling event but didn't attempt to get transportation of any form for Resident #51 to receive medically necessary dialysis. ASM #450 stated in the days leading up to Resident #51's admission to the hospital after missing dialysis she looked pale, she was sleeping a lot and typically she was a very active person, always awake and utilized her call light often which she hadn't been doing, and hadn't voided. Interview on 08/04/25 at 8:40 A.M. with ASM #451 revealed for about a week (the week of 07/20/25) the facility did not have a transportation van. This resulted in several residents missing appointments. The ASM voiced administration did not attempt to get transportation for the residents, it didn't seem like they cared. Resident #51 missed her dialysis appointments, for two days, she hadn't been to dialysis since 07/18/25 so she hadn't been to dialysis in five days leading up to her discharge to the hospital. The ASM stated administration didn't seem to care. Interview on 08/04/25 at 9:30 A.M. with Dialysis RN #607 confirmed Resident #51 missed her dialysis appointment on 07/21/25 and 07/23/25. RN #607 stated Resident #51 had not been to dialysis for two appointments totaling five days without being dialyzed, and Resident #51 was very compliant with dialysis, she didn't miss. The two days that were missed were due to the facility not having transportation to get Resident #51 to dialysis. RN #607 stated on Monday they asked the facility if the resident could attend dialysis Tuesday 07/22/35 and the facility reported the earliest they could get Resident #51 to dialysis was on Wednesday 07/23/25. RN #607 stated Resident #51's dialysis appointments typically began around 10:30 A.M. On 07/23/25 when it became apparent Resident #51 was not going to make it to her dialysis appointment the dialysis facility called the facility to recommended Resident #51 be transferred to the hospital fairly immediately; however, the resident was not sent until later that evening. Dialysis RN #607 stated it was not safe for someone to miss a dialysis appointment; this could cause fluid overload putting a burden on the resident's heart. Missing dialysis could also cause your potassium to rise causing hyperkalemia and anomalies with heart rhythm all the way up to cardiac arrest. Interview on 08/04/25 at 10:15 A.M. with DON #7

Based on record review, medication incident report form review, employee file review, policy review and interview the facility failed to ensure Resident #40 and Resident #44 received scheduled and/or as needed pain medication timely to provide effective pain relief/pain management. This affected two residents (Resident #40 and #44) of three residents reviewed for pain management. Actual harm occurred to Resident #40 when Licensed Practical Nurse #66 failed to administer scheduled pain medication as ordered resulting in the resident voicing severe pain, rated a ten on a scale of one to ten, which prevented her from engaging in the activities of daily living that she preferred. Findings include: 1. Review of Resident #40's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident's plan of care, dated 11/27/17 revealed the resident had potential for pain. Interventions included to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Review of the current physician's orders [REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/04/18, revealed Resident #40 was cognitively intact and required extensive assistance from two staff with bed mobility, dressing, toilet use and personal hygiene. The resident was also dependent on two staff for transfers. The assessment revealed the resident was on a scheduled pain medication regimen and received no as needed medications for pain. Further review revealed the resident experienced frequent pain during the assessment period with a rating of five on a 1-10 pain scale. Review of the pain tool dated 02/14/18 (not timed) revealed the resident experienced aching, bilateral lower leg pain rated a two on a 1-10 pain scale. Medications and the weather made the pain better. Further review revealed pain affected the resident's ability to sleep and rest, physical activity, mobility and emotions. The tool revealed medications and resting helped alleviate the pain. Review of the Controlled Substance Record revealed the nurse documented the administration of [MEDICATION NAME] 5/325 mg on 02/14/18 at 12:00 P.M. as ordered. However, review of a Medication Incident Report Form, dated 02/14/18 revealed the resident's pain medication ([MEDICATION NAME]), scheduled for 12:00 P.M., was not given until after 2:30 P.M. The form revealed due to the error the resident complained of pain. On 03/07/18 at 10:55 A.M. interview with Registered Nurse (RN) #70 revealed an incident occurred on 02/14/18 when Resident #40 did not receive her scheduled dose of [MEDICATION NAME] for pain which caused distress to Resident #40. The RN revealed the resident had to ask for the pain medication after it had not been administered as ordered. On 03/07/18 at 11:45 A.M. during an interview with Resident #40, the resident voiced concerns related to her pain medication. The resident shared an incident that had occurred around Valentine's Day when the nurse did not bring her noon dose of [MEDICATION NAME]. The resident stated as the afternoon went on, she began having severe pain, rating her pain a 10 on a scale of 1-10 and stated she asked if she had received the medication. The resident stated the pain was in her legs and hands and stated she was unable to watch television or nap, both activities she enjoyed because she was having so much pain. On 03/07/18 at 11:45 A.M. Resident #39, a friend of Resident #40, who was visiting in the room with Resident #40 during the above interview, also shared the following information. Resident #39 stated she was in the room the day Resident #40 received her pain medication late and stated Resident #40 was miserable. Resident #39 revealed she could not get Resident #40 to participate in anything after the incident occurred because she was in so much pain. On 03/07/18 at 12:30 P.M. interview with Licensed Practical Nurse (LPN) #50 verified LPN #66 administered pain medication to Resident #40 late on 02/14/18. On 03/07/18 at 2:45 P.M. interview with the Interim Director of Nursing (DON) verified the scheduled pain medication for Resident #40 was given late on 02/14/18. The resident had asked about her scheduled pain medication and the unit manager (LPN #50) checked the medication cart and identified the narcotic medication [MEDICATION NAME] had not been given. The DON verified the narcotic administration record documented the medication was administered at 12:00 P.M., however it was determined that LPN #66 had falsified the documentation regarding the administration time. The DON verified the resident had increased pain, which affected her daily routine as a result of LPN #66 not giving the pain medication as ordered. The DON also revealed LPN #66 was terminated as a result of not administering pain medications as ordered. Review of LPN #66's employee status change form, dated 02/15/18 revealed LPN #66 was terminated due to failure to meet job expectations and responsibilities. Review of the undated pain policy revealed pain management was defined as the process of alleviating the resident's pain to a level that was acceptable to the resident and was based on his or her clinical condition and established treatment goals. Review of the Job Description and Performance Standards for the facility LPN staff, dated 01/07/10 revealed the nurse was to administer treatments according to the physician's orders [REDACTED]. 2. Review of Resident #44's closed medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the pain medicine therapy related to chronic right lower extremity plan of care, dated 12/29/17, revealed interventions included administer [MEDICATION NAME] medication as ordered by the physician and monitor for pain medication efficacy. Review of the 30 day MDS 3.0 assessment, dated 01/25/18, revealed the resident was cognitively intact and required extensive assistance of two staff members with bed mobility, dressing, toilet use and personal hygiene. The resident was dependent of two staff with transfers. The resident received scheduled and as needed pain medications. The resident experienced frequent pain over the last five days during the assessment period with the worst pain being a seven out of a 1-10 pain scale. Review of the pain assessment tool dated 02/14/18 revealed the resident had generalized constant, stabbing pain in her right leg rated as a three on a 1-10 pain scale. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of the nursing progress notes dated 02/14/18 revealed no documentation regarding the incident on 02/14/18. Review of a fax communication form, dated 02/14/18 at 2:44 P.M., revealed the pharmacy approved for the facility to pull [MEDICATION NAME] from the contingency stock for Resident #44. Review of the controlled medication replacement and documentation form dated 02/14/18 revealed the [MEDICATION NAME] was not pulled from contingency until 02/14/18 at 5:00 P.M. Review of the Controlled Substance Record dated 02/14/18 revealed one [MEDICATION NAME] was administered to Resident #44 at 5:10 P.M. Review of the Medication Incident Report dated 02/14/18 revealed the resident requested PRN pain medication. The facility requested authorization to pull from the contingency box and permission was received on 02/14/18. LPN #50 documented she attempted multiple times to have the nurse pull the medication but the medication was not pulled until 5:00 P.M. The resident was assessed and, per the documentation, stated I'm ok. On 03/07/18 at 12:30 P.M. interview with LPN #50 verified she had knowledge of the resident needing pain medication and was waiting by the fax machine for authorization to pull the [MEDICATION NAME] for Resident #44. The LPN shared the fax came across around 2:30 P.M. and she informed LPN #66 the resident had the medication available. LPN #50 shared she had a difficult time keeping LPN #66 on task and had to remind her multiple times to administer the PRN medication. LPN #50 stated she did not intervene and administer the pain medication because LPN #66 was the nurse on the unit. On 03/07/18 at 2:45 P.M. interview with the DON verified LPN #66 was terminated as a result of not administering pain medications as ordered. Review of the Job Description and Performance Standards for the facility LPN staff, dated 01/07/10, revealed the nurse was to administer treatments according to the physician's orders [REDACTED]. This deficiency substantiates Complaint Number OH 570. This deficiency is also an example of continued non-compliance from the Annual Survey completed on 12/22/17.

Based on observations, resident and staff interviews, review of medical records staffing schedules, facility abuse investigations, personnel record, and the facility abuse policy and procedure, the facility failed to prevent and protect residents from an alleged incident of staff to resident physical abuse. This resulted in Immediate Jeopardy for Resident #7 when on 12/05/17 the resident reported to the State surveyor he had been physically abused by State tested Nurse Aide (STNA) #100 the prior week and nothing had been done. Resident #7 stated STNA #100 held him down in bed by his arms with such force that he sustained bruising to both arms, after he had requested to speak to the nurse. The potential for actual harm occurred, when following facility notification of the incident, STNA #100 was permitted to continue to provide direct care to all facility residents until he was suspended on 12/06/17. In addition, the facility failed to prevent an incident of verbal abuse and neglect, involving Resident #21. This affected two residents (Resident #7 and #21) reviewed for abuse and neglect and had the potential to affect all 59 residents residing in the facility. On 12/07/17 at 12:55 P.M. the Administrator, Regional Director of Nursing (DON), and Regional Director of Operations were notified that Immediate Jeopardy began on 12/05/17, when following an allegation of physical abuse, STNA #100 was permitted to continue to provide direct care to residents due to a lack of staff available to work in the facility. The Immediate Jeopardy was removed on 12/13/17 when the facility initiated the following corrective actions: · On 12/06/17, the facility initiated an investigation regarding the allegation of abuse made to the state surveyor on 12/05/17 by Resident #7. · On 12/07/17 at 1:28 P.M., the Administrator reported Resident #7's allegation of physical abuse to the State Agency. · On 12/07/17, STNA #100's employment was terminated by the facility. · On 12/07/17, Unit Manager/Registered Nurse (RN) #20 and Licensed Practical Nurse (LPN) #12 with the assistance of STNA #11, completed a whole house skin audit to identify any undocumented skin alterations. Any identified undocumented skin issues were resolved at the time of the audit. · On 12/07/17, Social Service Designee (SSD) #125 initiated a resident questionnaire. Fifty two residents, identified to be alert and oriented were asked Have you recently had any reason to feel unsafe in the facility. No residents interviewed reported they had felt unsafe. · On 12/07/17, the Director of Clinical Services provided in-service education to the Administrator related to the facility abuse policy and investigation process for complaints or self-reported incidents. · On 12/07/17, RN #20 began in-servicing all facility staff on the current policy and procedure regarding abuse and abuse reporting including the definitions of abuse. A plan for all staff to be in-serviced by 12/08/17 was provided. Any staff not educated by 12/08/17 would be unable to return to work until the in-service was completed. As of 12/08/17, 18 staff members were identified to have not received the in-service training. As of 12/10/17, all staff had received the in-service training either in person or via telephone. · On 12/08/17, 13 residents identified to be interviewable, who resided on the same unit as Resident #7, were interviewed and asked, Have you ever experienced abuse while in the facility? No residents reported any situations of abuse. · On 12/08/17 and 12/09/17, all interviewable residents were asked, Have you ever experienced abuse while in the facility? These interviews were completed by the Interdisciplinary Team/guardian angles during rounds. Staff members conducting the above interviews included the dietary manager, Human Resource Director, Business Office Manager, Activities Director, Environmental Services Supervisor, Medical Records, Minimum Data Set (MDS) Coordinator, Director of Nursing, Admissions Director, Assistant Director of Nursing, Therapy Director and Maintenance Director. As a result of these interviews, no concerns were identified. However, on 12/08/17, Resident #51 reported an allegation of neglect related to care concerns identified on the night shift. As of 12/13/17, the facility was in the process of completing this investigation. · On 12/12/17, Activity Director (AD) #126 conducted a resident council meeting. Residents #42, #26, #24, #36, #39, #257, #3, #27 and #8 present at the meeting were educated related to the facility abuse policy and abuse reporting. Residents who were not present at the meeting were visited by their guardian angel and education was provided one on one regarding the facility abuse policy and reporting. Three residents currently in the hospital will receive the education upon their return. A plan for discussing the facility abuse policy and reporting with family members was initiated to be done on admission and during quarterly care conferences. · On 12/12/17 from 4:00 P.M. to 4:30 P.M., the Administrator and Regional Director of Operations conducted a mandatory staff meeting with 56 staff in attendance. The content of the education included the abuse policy, the definitions of abuse, reinforcement of the Administrator being the abuse coordinator and his contact information was provided. Nine employees (three agency and 6 facility staff), who were assigned to work night shift and who were not present at the meeting were educated prior to their shift beginning. A plan for the remaining 24 staff to be educated prior to the start of their next shift was developed. · Beginning 12/13/17, the facility will provide written abuse education materials to all agency staff working in the building. · On 12/13/17, statements from staff, including STNA #59, RN #18, STNA #36, STNA #89 and STNA #78 were obtained regarding observations of and/or any knowledge of incidents of abuse by STNA #100 toward Resident #7 or any other resident. · On 12/13/17, a plan for the Administrator to log all allegations of abuse, neglect, misappropriation and communicate initial and final reports to the Director of Clinical Services and/or the Regional Director of Operations for all allegations of abuse will be completed. The Director of Clinical Services or Regional Director of Operations would monitor for compliance of reporting through the Self-Reported Incident Log weekly for two months and then monthly for an indefinite time period. The results will be reviewed with monthly performance improvement to continue focus for quality improvement measures. · On 12/13/17, the facility initiated a system that all new admissions beginning on 12/13/17 (for an indefinite time period) would be interviewed by the Social Services Director/designee during the resident's initial admission care conference regarding situations of abuse. The Administrator will follow up with any identified concerns. · Beginning 12/13/17, guardian angel rounds completed weekly will specifically ask questions regarding abuse/neglect/misappropriation. The outcome of the rounds will be discussed during daily Interdisciplinary Team Meetings with any concerns being immediately reported and investigated for an indefinite time period. · Beginning 12/13/17, the Administrator will utilize an Abuse Event Checklist, Alleged Abuse, Neglect and Exploitation Investigation Worksheet to ensure the investigation process was initiated and completed thoroughly. The Administrator was to sign completion of investigations upon validation of completion. · Beginning 12/13/17, a plan for the Administrator, Director of Clinical Services and/or Regional Director of Operations to monitor the Investigation procedure through use of a self-reported incident log for three months with review at the performance improvement meeting monthly to continue focus for quality improvement measures as indicated. · Between 12/11/17 and 12/13/17, interview with Agency Licensed Practical Nurse (LPN) #127, STNA 78, STNA #59, STNA #99, STNA #93 and Housekeeper #3 revealed they were knowledgeable of the facility abuse policy and reporting requirements for abuse. Although the Immediate Jeopardy was removed on 12/13/17, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) related to ongoing staff education regarding the facility abuse policy, on-going random audits, resident/family interviews, monitoring to ensure continued resident safety and provision of residents with an opportunity to express concerns. Findings include: 1. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #7's cognition was assessed to be moderately impaired. The quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/06/17 indicated the resident was dependent on staff for personal hygiene, locomotion, transfers and required extensive assist from staff with bed mobility, dressing, eating, and toilet use. The resident did not have any behavioral symptoms or display rejection of care. Resident #7 was noted to always be incontinent of bowel and bladder. The medical record contained no documentation of bruising to Resident #7's arms. Review of a facility statement of events, contained an administrative file dated 11/20/17 to 11/23/17 indicating housekeeping staff found unflushed urine and feces in Resident #7's toilet which was reported to the nurse. During a facility investigation, Resident #7 reported STNA #100 had used his toilet. The resident stated STNA #100 told him to go to sleep and not to worry about it. A statement from STNA #57 verified STNA #100 worked on the resident's unit between 11/20/17 and 11/23/17. A statement from STNA #100 denied the allegation. However, because of the incident, the Administrator instructed STNA #100 should not enter Resident #7's room in the future. There was no evidence to ensure how staff, including STNA #100 were made aware of this or evidence the facility followed up with Resident #7 following the incident. On 12/05/17 at 11:23 A.M., during an interview with Resident #7, the resident was asked if he had ever been abused or mistreated by staff. The resident shared an incident that occurred in which STNA #100 had held him down the previous week when he requested to talk to the nurse. When the resident would not tell the STNA why he wanted the nurse the STNA held both arms down and said No, you will tell me what you want. The resident reported the STNA had caused bruising to his arms when he held him down and proceeded to show the surveyor the bruising. The resident voiced he was afraid of STNA #100 and indicated he had reported the incident to the Administrator at the time it had occurred. On 12/05/17 at 11:52 A.M., interview with the Administrator revealed he was not aware of the physical abuse allegation last week. The surveyor shared the information provided by Resident #7 as noted above. The Administrator verified STNA #100 was not permitted in Resident #7's room due to an incident regarding the resident's toilet. On 12/05/17 at 5:20 P.M., interview and observation of Resident #7 with Licensed Practical Nurse (LPN) #36 revealed Resident #7 had multiple bruises on his right arm in various healing stages. LPN #36 revealed there were no skin alteration sheets for the bruising on the treatment administration record (TAR) and no nursing progress notes to identify when the bruises were first noted or what the bruises were from. On 12/05/17 at 6:06 P.M., interview with STNA #100 revealed Resident #7 had reported him for mental abuse a few weeks ago. He alleged STNA #100 used his toilet and did not flush. STNA #100 verified he was suspended a day and half pending the investigation. He denied he did it and was unaware of the resident making any other allegations of abuse. He denied that he had ever forcibly held down the resident against his will or any other residents and denied seeing any other employee do the same . On 12/06/17 at 8:43 A.M., interview with the Administrator revealed he had not started any type of investigation related to the allegation made by Resident #7 of STNA #100 physically abusing him one day last week and verified even after discussing the concern on 12/05/17 at 11:53 A.M., STNA #100 worked on 12/05/17 during the 3:00 P.M. to 11:00 P.M. shift providing care for Resident #7 and all the residents on the South unit. The Administrator stated STNA #100 was not supposed to work on South unit, effective 11/21/17 (from the previous incident with Resident #7 as noted above); however due to staff shortage he had no other choice. On 12/06/17 at 2:55 P.M., interview and observation of Resident #7 with LPN #101 revealed the resident reported STNA #100 held him down causing bruises on his arms a week ago. The resident reported he told STNA #100 he wanted to see a nurse and STNA #100 replied No, you can tell me. The resident responded no, I want the nurse and STNA #100 repeated No, you will talk to me. Resident #7 indicated he was afraid of STNA #100. The red bruised areas on the right arm had the appearance of finger marks near the right elbow and a red bruised area near the left elbow. LPN #101 reported she would write a statement regarding the interview and observation. She verified there was no documentation in the medical record regarding the bruising. On 12/06/17 at 3:30 P.M., interview and observation of Resident #7 with the Administrator and Registered Nurse (RN) #5 revealed Resident #7 had marks on his right arm (near his elbow) that had the appearance of finger marks and the left arm had a large red bruised area in the same area as the right. The resident reported STNA #100 held him down causing the bruising and he was afraid of STNA #100. On 12/06/17 at 3:48 P.M., interview with Administrator confirmed the areas on Resident #7 arms appeared suspicious. On 12/06/17 at 4:51 P.M., interview with STNA #207 revealed on 11/21/17 she received an e-mail not to schedule STNA #100 on the South unit. STNA #207 revealed she had to schedule STNA #100 to work on the South unit on 11/30/17, 12/01/17, 12/04/17, and 12/05/17 due to staffing shortage. On 12/07/17 at 8:38 A.M., interview with the DON confirmed Resident #7's allegations of physical abuse and the markings on his arms corroborated the allegation of abuse. The DON reported she was not aware of the abuse allegation until yesterday (12/06/17). On 12/07/17 at 10:27 A.M., interview with Administrator revealed no self-reported incident (SRI) to the State Agency related to this incident had been submitted. On 12/07/17 at 12:55 P.M., interview with the Administrator revealed he had submitted an SRI to the State Agency today and would start an investigation. The administrator stated STNA #100 had been suspended and he planned to terminate the STNA's employment. Review of LPN #101's statement of events, dated 12/06/17 at 2:55 P.M., revealed Resident #7 stated STNA #100 held him down causing bruises on his arms. Resident #7 reported he told STNA #100 he wanted to talk to the nurse and STNA #100 said No, you can talk to me. Resident #7 said No, I want the nurse and STNA #100 repeated No, you will talk to me. Resident #7 reported he was afraid. Review of STNA #100's personnel file revealed the STNA was hired on 03/02/17. There was no evidence of a 90-day performance evaluation being completed. Review of the employee's personnel file revealed a history of call-off's, tardiness and a no call no show. On 12/11/17 at 8:47 A.M. interview with the Administrator verified STNA #100 was not immediately suspended following notification of the allegation of physical abuse on 12/05/17. The Administrator again indicated that although the resident told the state surveyor he had reported the incident to him at the time it had occurred, he was not aware of it until it was shared by the surveyor on 12/05/17. The Administrator verified as of 12/11/17 he had not completed a thorough investigation including statements from other residents in regards to allegations of abuse. On 12/11/17 at 9:23 A.M. interview with the Administrator verified a skin sweep, completed on 12/07/17 was not comprehensive and did not include any type of assessment or measurements of the bruising that were identified to the resident's arms. A follow up skin assessment, dated 12/10/17 also failed to include any type of assessment or measurements of bruising that remained on the resident's arms. 2. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS 3.0 assessment, dated 07/10/17 and the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #21 was cognitively intact for daily decision-making and was always continent of urine. Review of STNA #1's Statement of Events, dated 09/04/17 revealed Resident #21's call light was on and the resident stated she had to urinate. STNA #1 told the resident she would have to wait because there were three other residents she needed to help before her. The resident called STNA #1 a (expletive) and STNA #1 restated the (expletive) stating that she was not a (expletive) today, tomorrow or the next day. STNA #1 then left Resident #21's room without taking her to the bathroom. Resident #21 was not taken to the bathroom until STNA #2 returned to the unit. Review of Resident #21's Statement of Events, dated 09/04/17 revealed she asked STNA #1 to take her to the bathroom and she said no. Resident #21 stated she called STNA #1 a 'curse' word and STNA #1 then turned off her call light, walked out of the room and later walked by the resident stating you are disgusting. Resident #21 stated Housekeeper (HSKP) #3 heard what STNA #1 said to her. Review of HSKP #3's Statement of Events, dated 09/04/17 revealed Resident #21 had used a 'curse' word towards STNA #1 at which time STNA #1 told the resident not to call her that. STNA #1 then turned off the resident's call light, told the resident she would have to wait for STNA #2 to return to the unit to provide care and informed the resident that she would not provide care to her. Review of the facility SRI submitted 09/05/17 revealed on 09/04/17 Resident #21 reported that an STNA had been mean to her and called her disgusting. The resident was initially crying when the allegation was reported. Review of the SRI documentation revealed a reference to staff on duty but did not include who the actual staff were at the time of incident who were interviewed. However, the SRI revealed STNA #1 talked to the resident inappropriately, refused to toilet the resident and turned off the call light without tending to the resident's needs. STNA #1 was interviewed and based on her statement, witness statements, and facility policy, the allegation of emotional/verbal abuse was substantiated. STNA #1's employment was terminated on 09/06/17 due to violation of the facility abuse policy and willful/reckless inattention to the needs of a resident. On 11/29/17 at 11:10 A.M., interview with the DON verified Resident #21 was verbally abused and neglected by STNA #1. Review of the facility abuse, neglect, exploitation and misappropriation of resident property policy, revised 10/27/17 revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of [REDACTED]. A nurse should perform an initial assessment of the resident. The assessment should generally include full body assessment for signs of injury. If a staff member was accused or suspected of abuse the facility should immediately remove the staff member from the facility and the schedule pending the outcome of the investigation. Facility staff should immediately report all such allegations to the administrator/designee and to the State Agency. The investigation of the allegation/violation will be conducted.

Based on observations, medical record reviews, review of staffing schedules, review of facility abuse investigations, review of a personnel record, review of the facility abuse policy and procedures, and resident and staff interviews, the facility failed to effectively implement their abuse policy and procedure to prevent incidents of staff to resident abuse and to ensure timely reporting and thorough investigations of all alleged incidents of abuse/neglect The failure to effectively implement the abuse policy and procedure to determine if actual abuse has occurred and the extent residents are affected and the staff involved, can put residents at risk for continued abuse and serious harm. The facility's failure to effectively implement their abuse/neglect policy and procedure resulted in Immediate Jeopardy on 11/30/17 when Resident #158 alleged State tested Nursing Assistant (STNA) #83 failed to provide incontinence care to her during the night shift resulting in serious harm as excoriation to her buttocks. STNA #61 entered Resident #158's room at 7:15 A.M. on 11/30/17 when she arrived on duty, found Resident#158 crying and upset with a large amount of stool dried to her skin. The resident's buttocks were observed red and starting to open. Resident #158 informed STNA #61 she had not been checked on by staff all night. The Immediate Jeopardy continued as on 12/05/17 Resident #7 reported to the state surveyor STNA #100 had physically abused him last week. In response to Resident #7 asking to speak to a nurse, STNA#100 held the resident down by both of his arms, bruising the resident. The potential for serious harm existed as after the facility was notified of this incident, STNA #100 continued to provide direct care to the residents until his suspension on 12/06/17. The facility also failed to ensure allegations of abuse alleged by Residents #21 and #39 were thoroughly investigated. This affected four (#7, #21, #39 and #158) residents reviewed for abuse and neglect and had the potential to affect all 59 residents residing in the facility. On 12/07/17 at 12:55 P.M., the Administrator, Regional Director of Nursing and Regional Director of Operations were notified that Immediate Jeopardy began on 11/30/17 when Resident #158 reported an allegation of neglect that was not thoroughly and timely investigated or timely reported to the State agency and the STNA continued to provide care. The Immediate Jeopardy continued as of 12/05/17, when Resident #7 reported an allegation of abuse that was not thoroughly investigated or reported to the State agency and the STNA involved in the incident continued to provide direct care. The Immediate Jeopardy was removed on 12/13/17 when the facility initiated the following corrective actions: · On 12/06/17, the facility initiated an investigation regarding the allegation of abuse made to the State surveyor on 12/05/17 by Resident #7. · On 12/07/17, at 1:28 P.M. the Administrator reported Resident #7's allegation of physical abuse to the State Agency. · On 12/07/1,7 STNA #100's employment was terminated by the facility. · On 12/06/17, the Administrator reported Resident #83's allegation of neglect to the State Agency. The investigation, which included staff statements, determined the incident occurred as a result of insufficient staff on duty on 11/30/17 at the time of the incident. · On 12/07/17, Unit Manager/Registered Nurse (RN) #20 and Licensed Practical Nurse (LPN) #12 with the assistance of STNA #11 completed a whole house skin audit, to identify any undocumented skin alterations. Any identified undocumented skin issues were resolved at the time of the audit. · On 12/07/17, Social Service Designee (SSD) #125 initiated a resident questionnaire. Fifty Two residents, identified to be alert and oriented were asked Have you recently had any reason to feel unsafe in the facility. No residents interviewed reported they had felt unsafe. · On 12/07/17, the Director of Clinical Services provided in-service education to the Administrator related to the facility abuse policy and investigation process for complaints or self-reported incidents. · On 12/07/17, RN #20 began in-servicing all facility staff on the current policy and procedure regarding abuse and abuse reporting including the definitions of abuse. A plan for all staff to be in-serviced by 12/08/17 was provided. Any staff not educated by 12/08/17 would be unable to return to work until the in-service was completed. As of 12/08/17, 18 staff members were identified to have not received the in-service training. As of 12/10/17 all staff had received the in-service training either in person or via telephone. · On 12/08/17 and 12/09/17, all interviewable residents were asked, Have you ever experienced abuse while in the facility? These interviews were completed by the Interdisciplinary team/guardian angles during rounds. Staff members conducting the above interviews included the dietary manager, Human Resource Director, Business Office Manager, Activities Director, Environmental Services Supervisor, Medical Records, Minimum Data Set (MDS) Coordinator, Director of Nursing, Admissions Director, Assistant Director of Nursing, Therapy Director and Maintenance Director. As a result of these interviews, no concerns were identified. However, on 12/08/17 Resident #51 reported an allegation of neglect related to care concerns identified on the night shift. As of 12/13/17, the facility was in the process of completing this investigation. · On 12/12/17, Activity Director (AD) #126 conducted a resident council meeting. Residents #42, #26, #24, #36, #39, #257, #3, #27 and #8 present at the meeting were educated related to the facility abuse policy and abuse reporting. Residents who were not present at the meeting were visited by their guardian angel and education was provided one on one regarding the facility abuse policy and reporting. Three residents currently in the hospital will receive the education upon their return. A plan for discussing the facility abuse policy and reporting with family members was initiated to be done on admission and during quarterly care conferences. · On 12/12/17 from 4:00 P.M. to 4:30 P.M., the Administrator and Regional Director of Operations conducted a mandatory staff meeting with 56 staff in attendance. The content of the education included the abuse policy, the definitions of abuse, reinforcement of the Administrator being the abuse coordinator and his contact information was provided. Nine employees (three agency and 6 facility staff), who were assigned to work night shift and who were not present at the meeting were educated prior to their shift beginning. A plan for the remaining 24 staff to be educated prior to the start of their next shift was developed. · Beginning 12/13/17, the facility will provide written abuse education materials to all agency staff working in the building. · On 12/13/17, statements from staff, including STNA #59, RN #18, STNA #36, STNA #89 and STNA #78 were obtained regarding observations of and/or any knowledge of incidents of abuse by STNA #100 toward Resident #7 or any other resident. · On 12/13/17, a plan for the Administrator to log all allegations of abuse, neglect, misappropriation and communicate initial and final reports to the Director of Clinical Services and/or the Regional Director of Operations for all allegations of abuse will be completed. The Director of Clinical Services or Regional Director of Operations would monitor for compliance of reporting through the Self-Reported Incident Log weekly for two months and then monthly for an indefinite time period. The results will be reviewed with monthly performance improvement to continue focus for quality improvement measures. · On 12/13/17, the facility initiated a system that all new admissions beginning on 12/13/17 (for an indefinite time period) would be interviewed by the Social Services Director/designee during the resident's initial admission care conference regarding situations of abuse. The Administrator will follow up with any identified concerns. · Beginning 12/13/17, guardian angel rounds completed weekly will specifically ask questions regarding abuse/neglect/misappropriation. The outcome of the rounds will be discussed during daily Interdisciplinary Team Meetings with any concerns being immediately reported and investigated for an indefinite time period. · Beginning 12/13/17, the Administrator will utilize an Abuse Event Checklist, Alleged Abuse, Neglect and Exploitation Investigation Worksheet to ensure the investigation process was initiated and completed thoroughly. The Administrator was to sign completion of investigations upon validation of completion. · Beginning 12/13/17, a plan for the Administrator, Director of Clinical Services and/or Regional Director of Operations to monitor the Investigation procedure through use of a self-reported incident log for three months with review at the performance improvement meeting monthly to continue focus for quality improvement measures as indicated. · Between 12/11/17 and 12/13/17, interview with Agency Licensed Practical Nurse (LPN) #127, STNA 78, STNA #STNA #59, STNA #99, STNA #93, Housekeeper #3 revealed they were knowledgeable of the facility abuse policy and reporting requirements for abuse. Although the Immediate Jeopardy was removed on 12/13/17, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) related to ongoing staff education regarding the facility abuse policy, on-going random audits, resident/family interviews, monitoring to ensure continued resident safety and provision of residents with an opportunity to express concerns. Findings include: 1. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's cognition was assessed to be moderately impaired. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], indicated the resident was dependent on staff for personal hygiene, locomotion, transfers and required extensive assist from staff with bed mobility, dressing, eating, and toilet use. The resident did not have any physical, verbal, or any other behavioral symptoms or rejection of care. The resident was noted to be always incontinent of bowel and bladder. The paper and electronic medical record indicated no evidence of bruising. Review of a facility statement of events, contained in an administrative file, dated 11/20/17 to 11/23/17, revealed housekeeping staff found unflushed urine and feces in Resident #7's toilet which was reported to the nurse. During a facility investigation, Resident #7 reported STNA #100 had used his toilet and he told him not to. The resident stated STNA #100 told him to go to sleep and not to worry about it. A statement from STNA #57 verified STNA #100 worked on the resident's unit between 11/20/17 and 11/23/17. A statement from STNA #100 denied the allegation. However, because of the incident, the Administrator instructed STNA #100 not to enter Resident #7's room in the future. There was no evidence to ensure how staff, including STNA #100 were made aware of this or evidence the facility followed up with Resident #7 following the incident. On 12/05/17 at 11:23 A.M., during an interview with Resident #7, the resident was asked if he had ever been abused or mistreated by staff. The resident shared an incident that occurred in which STNA #100 had held him down last week when he requested to talk to the nurse. When the resident would not tell the STNA why he wanted the nurse the STNA held both arms down and said No, you will tell me what you want. The resident reported the STNA had caused bruising to his arms when he held him down and proceeded to show the surveyor the bruising. The resident voiced he was afraid of STNA #7 and indicated he had reported the incident to the Administrator at the time it had occurred. On 12/05/17 at 11:52 A.M., interview with the Administrator revealed he was not aware of the physical abuse allegation last week. The surveyor shared the information provided by Resident #7 as noted above. The Administrator verified STNA #100 was not permitted in Resident #7's room due to incident regarding the resident's toilet. On 12/06/17 at 8:43 A.M., interview with the Administrator revealed he had not started any type of investigation related to the allegation made by Resident #7 of STNA #100 physically abusing him one day last week and verified even after discussing the concern on 12/05/17 at 11:53 A.M., STNA #100 worked on 12/05/17 during the 3:00 P.M. to 11:00 P.M. shift providing care for Resident #7 and all the residents on the South unit. The Administrator stated STNA #100 was not supposed to work on South unit, effective 11/21/17 (from the previous incident with Resident #7 as noted above), however due to staff shortage he had no other choice. On 12/06/17 at 2:55 P.M., interview and observation of Resident #7 with Licensed Practical Nurse (LPN) #101 revealed the resident reported STNA #100 held him down causing bruises on his arms a week ago. The resident reported he told STNA #100 he wanted to see a nurse and STNA #100 replied No, you can tell me. The resident responded no, I want the nurse and STNA #100 repeated No, you will talk to me. Resident #7 indicated he was afraid of STNA #100. The red bruised areas on the right arm had the appearance of fingermarks near the right elbow and a red bruised area near the left elbow. LPN #101 reported she would write a statement regarding the interview and observation. She verified there was no documentation in the medical record regarding the bruising. On 12/06/17 at 3:30 P.M., interview and observation of Resident #7 with the Administrator and Registered Nurse (RN) #5 revealed Resident #7 had marks on his right arm (near elbow) that have the appearance of fingermarks and the left arm had a large red bruised area in the same area as the right. The resident reported STNA #100 held him down causing the bruising and he was afraid of STNA #7. On 12/06/17 at 3:48 P.M., interview with Administrator confirmed the areas on Resident #7 arms appeared suspicious. On 12/07/17 at 10:27 A.M., interview with Administrator revealed no self-reported incident (SRI) related to this incident had been submitted to the State Agency as of this time. On 12/07/17 at 12:55 P.M., interview with the Administrator revealed he had submitted an SRI to the State agency today and would start an investigation. The administrator stated STNA #100 had been suspended and he planned to terminate the STNA's employment. Review of STNA #100's personnel file revealed the STNA was hired on 03/02/17. There was no evidence of a 90-day performance evaluation being completed. Review of the employee's personnel file revealed a history of call-off's, tardiness and a no call no show. As of 12/11/17 at 8:47 A.M., interview with the Administrator verified STNA #100 was not immediately suspended following notification of the allegation of physical abuse on 12/05/17. The Administrator again indicated, that although the resident told the State surveyor he had reported the incident to him at the time it had occurred, he was not aware of it until the State surveyor shared the concern on 12/05/17. The Administrator verified on 12/08/17 the facility conducted interviews with current residents, asking only Have you recently had any reason to feel unsafe in the facility? After discussing the corrective action taken in regard to resident interviews, the facility provided additional resident interviews, for resident's residing on the South unit, asking, Have you ever experienced abuse in the facility. As of 12/11/17, he had not completed a thorough investigation including statements from other residents or from any staff members in regards to allegations of abuse. On 12/11/17 at 9:23 A.M., interview with the Administrator revealed a skin sweep, completed on 12/07/17, was not comprehensive and did not include any type of assessment or measurements of bruising that was identified to the resident's bilateral arms. A follow up skin assessment, dated 12/10/17 also failed to include any type of assessment or measurements of bruising that remained on the resident's bilateral arms. 2. Record review revealed Resident #158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission assessment dated [DATE], revealed the resident was alert and oriented, did not have skin alterations to her buttocks and was continent of bowel. At the time of admission, the resident had an indwelling catheter. Review of the admission pressure ulcer risk assessment revealed the resident was at risk for pressure ulcer development. Review of a plan of care for Activities of Daily Living (ADL) care performance deficit dated 11/27/17, revealed the resident required extensive assistance of two staff members with turning and repositioning in bed and toilet use. Review of the nursing progress note, dated 11/23/17 at 1:41 A.M., revealed the resident was continent of bowel. Review of a nursing progress note, dated 12/01/17 at 1:54 P.M., revealed Resident #158 had excoriation (beefy, red denuded skin) to the buttocks with new orders to apply a foam dressing to the buttocks daily. The medical record did not contain further documentation related to the cause of the excoriation or a physician's orders [REDACTED]. During an interview with Resident #158 on 12/05/17 at 11:54 A.M., and a follow up interview on 12/06/17 at 3:00 P.M., the resident shared she had concerns related to the facility staffing and an incident that had recently occurred. The resident stated she was aware of when she needed to use the bathroom to move her bowels. The resident stated a few days prior she had to move her bowels and was unable to activate her call light due to the placement of the call light and the light being wrapped around her right arm. The resident stated the door to her room was closed and since she was unable to reach her call light, she started to yell out. She stated she waited and waited, however, no staff came. The resident stated because no one came, she laid in feces all night. The resident stated this caused her skin to breakdown and she was very sore. The resident stated she considered what the staff did to her was abuse and stated she had shared this concern with the staff at the time it occurred. The resident said she also told her husband, when he came in that morning and he immediately shared the concerns with the Administrator. Further interview revealed by the time she was discovered the following morning, she was crying and upset because she felt scared and felt no one was there to care for her. The resident stated STNA #83, who failed to answer calls for help and help her to use the bathroom, had continued to provide care to her since the incident. On 12/06/17 at 4:30 P.M., interview with the Administrator revealed he was aware of the above incident but thought it was a customer service issue and not an issue of abuse or neglect. At the time of the interview, the Administrator was unable to provide evidence of a thorough investigation including a statement from the resident, statements from any other residents regarding the care they had received the same night, statements from the staff working at the time of the incident or statements from the staff who had knowledge or involvement in the incident. The Administrator also failed to provide evidence the facility investigated the staffing level in the facility at the time of the incident to ensure adequate staff was deployed to meet the resident's needs. On 12/06/17, the Administrator submitted a self-reported incident, tracking number 6 related to an allegation of neglect/mistreatment/abuse involving Resident #158. The initial reporting revealed the resident alleged staff left her lay in feces all night. The effect noted to the resident indicated the resident was upset that she was not changed for her incontinent episode during the night. Review of the staffing schedules revealed following the above identified concern, STNA #83 continued to work and provide resident care on 12/03/17. On 12/08/17 at 9:30 A.M., interview with Resident #158's spouse revealed he spoke with the administrator after his wife informed him she laid in feces all night and no one checked on her or changed her soiled clothing. The resident's husband verified he believed Resident #158 experienced skin break down due to not being provided timely incontinence care. 3. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS 3.0 assessment dated [DATE], and the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #21 was cognitively intact for daily decision-making and was always continent of urine. Review of STNA #1's Statement of Events dated 09/04/17, revealed Resident #21's call light was on and the resident stated she had to urinate. STNA #1 told the resident she would have to wait because there were three other residents she needed to help before her. The resident called STNA #1 a 'curse' word and STNA #1 restated the 'curse' word stating that she was not the 'curse' word today, tomorrow or the next day. STNA #1 then left Resident #21's room without taking her to the bathroom. Resident #21 was not taken to the bathroom until STNA #2 returned to the unit. Review of Resident #21's Statement of Events dated 09/04/17, revealed she asked STNA #1 to take her to the bathroom and she said no. Resident #21 stated she called STNA #1 a 'curse' word and STNA #1 then turned off her call light, walked out of the room and later walked by the resident stating you are disgusting. Resident #21 stated Housekeeper (HSKP) #3 heard what STNA #1 said to her. Review of HSKP #3's Statement of Events dated 09/04/17, revealed Resident #21 had used a 'curse' word towards STNA #1 at which time STNA #1 told the resident not to call her that. STNA #1 then turned off the resident's call light, told the resident she would have to wait for STNA #2 to return to the unit to provide care and informed the resident that she would not provide care to her. Review of the facility SRI submitted 09/05/17, revealed on 09/04/17, Resident #21 reported that an STNA had been mean to her and called her disgusting. The resident was initially crying when the allegation was reported. Staff on duty at the time of the incident were interviewed and verified STNA #1 talked to the resident inappropriately, refused to toilet the resident and turned off the call light without tending to the resident's needs. STNA #1 was interviewed and based on her statement, witness statements, and facility policy, the allegation of emotional/verbal abuse against STNA #1 was substantiated. STNA #1's employment was terminated on 09/06/17, due to violation of the facility abuse policy and willful/reckless inattention to the needs of a resident. Review of the SRI, submitted 09/05/17, revealed substantiated verbal abuse involving Resident #21. Review of the facility abuse investigation dated 09/04/17 through 09/08/17, revealed two random residents were interviewed to determine if others were affected by abuse. Review of the abuse investigation Statement of Events dated 09/08/17, revealed Director of Social Services (DSS) #4 asked Resident #39 if she was aware of any staff speaking inappropriately to residents. Resident #39 stated a certain nurse was always picking on her and was snippy. Resident #39 also stated she heard staff speaking inappropriate to other residents, nurse aides no longer at the facility had been mean to the residents and she was told to mind her own business. Review of Resident #39's statement revealed no documented evidence the allegations of abuse were reported to the Administrator or investigated. Review of the State agency SRI documentation revealed no evidence Resident #39's allegations of abuse from an interview conducted on 09/08/17, by DSS #4 had been reported to the state agency. On 11/29/17 at 11:10 A.M., interview with the Director of Nursing (DON) verified Resident #21 was verbally abused and neglected by STNA #1. During the interview the DON also verified DSS #4 only interviewed two random residents after a substantiated abuse allegation on 09/04/17. The DON verified one of the two residents interviewed reported an allegation of abuse. The DON stated DSS #4 no longer worked at the facility, verified DSS #4 did not report the allegation of abuse, the allegation had not been reported to the state agency and the allegation had not been investigated. Review of the facility abuse, neglect, exploitation and misappropriation of resident property policy, revised 10/27/17, revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of [REDACTED]. A nurse should perform an initial assessment of the resident. The assessment should generally include full body assessment for signs of injury. If a staff member was accused or suspected of Abuse the facility should immediately remove the staff member from the facility and the schedule pending the outcome of the investigation. Facility staff should immediately report all such allegations to the administrator/designee and to the State agency. The investigation of allegation/violation will be conducted.

Based on observations, resident and staff interviews, review of medical records, staffing schedules, facility abuse investigations, personnel record and the facility abuse policy and procedure, the facility failed to ensure all allegations of abuse and neglect were immediately reported to the Administrator and/or State agency as required. This resulted in Immediate Jeopardy on 11/30/17 when Resident #158 alleged State tested Nursing Assistant (STNA) #83 failed to provide incontinence care to her during the night shift resulting in excoriation to her buttocks. Actual harm occurred when STNA #61 entered Resident #158's room at 7:15 A.M., when she arrived on duty, found the resident crying and upset and identified the resident had a large amount of stool that was dried to her skin. The resident's buttocks were observed to be red and starting to open. Resident #158 informed STNA #61 she had not been checked on by staff all night. The Immediate Jeopardy continued on 12/05/17 when Resident #7 reported to the State surveyor he had been physically abused by STNA #100, who had held him down by both his arms in bed, the week prior, after asking to speak to the nurse. The potential for actual harm occurred, when following notification of the incident, STNA #100 was permitted to continue to provide direct care to all facility residents until he was suspended on 12/06/17. In addition the facility failed to ensure allegations of abuse identified by Resident #39 were reported as required. This affected three residents (Resident #7, #39, and #158) reviewed for abuse and neglect and had the potential to affect all 59 residents residing in the facility. On 12/07/17 at 12:55 P.M., the Administrator, Regional Director of Nursing, and Regional Director of Operations were notified Immediate Jeopardy began on 11/30/17 when Resident #158 reported an allegation of neglect that was not reported as required and the STNA involved in the incident continued to work. The Immediate Jeopardy continued 12/05/17, when Resident #7 reported an allegation of abuse that was not reported as required and the STNA involved in the incident continued to work. The Immediate Jeopardy was removed on 12/13/17 when the facility initiated the following corrective actions: · On 12/06/17, the facility initiated an investigation regarding the allegation of abuse made to the state surveyor on 12/05/17 by Resident #7. · On 12/07/17 at 1:28 P.M., the Administrator reported Resident #7's allegation of physical abuse to the State Agency. · On 12/07/17, STNA #100's employment was terminated by the facility. · On 12/06/17, the Administrator reported Resident #83's allegation of neglect to the State Agency. The investigation determined the incident occurred as a result of insufficient staff on duty on 11/30/17 at the time of the incident. · On 12/07/17, Unit Manager/Registered Nurse (RN) #20 and Licensed Practical Nurse (LPN) #12 with the assistance of State tested Nursing Assistant (STNA) #11 completed a whole house skin audit, to identify any undocumented skin alterations. Any identified undocumented skin issues were resolved at the time of the audit. · On 12/07/17, Social Service Designee (SSD) #125 initiated a resident questionnaire. Fifty Two residents, identified to be alert and oriented were asked Have you recently had any reason to feel unsafe in the facility. No residents interviewed reported they had felt unsafe. · On 12/07/17, the Director of Clinical Services provided in-service education to the Administrator related to the facility abuse policy and investigation process for complaints or self-reported incidents. · On 12/07/17, RN #20 began in-servicing all facility staff on the current policy and procedure regarding abuse and abuse reporting including the definitions of abuse. A plan for all staff to be in-serviced by 12/08/17 was provided. Any staff not educated by 12/08/17 would be unable to return to work until the in-service was completed. As of 12/08/17, 18 staff members were identified to have not received the in-service training. As of 12/10/17, all staff had received the in-service training either in person or via telephone. · On 12/08/17, 13 residents identified to be interviewable, who resided on the same unit as Resident #7, were interviewed and asked, Have you ever experienced abuse while in the facility? No residents reported any situations of abuse. · On 12/08/17 and 12/09/17, all interviewable residents were asked, Have you ever experienced abuse while in the facility? These interviews were completed by the Interdisciplinary Team/guardian angles during rounds. Staff members conducting the above interviews included the dietary manager, Human Resource Director, Business Office Manager, Activities Director, Environmental Services Supervisor, Medical Records, Minimum Data Set (MDS) Coordinator, Director of Nursing, Admissions Director, Assistant Director of Nursing, Therapy Director and Maintenance Director. As a result of these interviews, no concerns were identified. However, on 12/08/17 Resident #51 reported an allegation of neglect related to care concerns identified on the night shift. As of 12/13/17, the facility was in the process of completing this investigation. · On 12/12/17, Activity Director (AD) #126 conducted a resident council meeting. Resident #42, #26, #24, #36, #39, #257, #3, #27 and #8 present at the meeting were educated related to the facility abuse policy and abuse reporting. Residents who were not present at the meeting were visited by their guardian angel and education was provided one on one regarding the facility abuse policy and reporting. Three residents currently in the hospital will receive the education upon their return. A plan for discussing the facility abuse policy and reporting with family members was initiated to be done on admission and during quarterly care conferences. · On 12/12/17 from 4:00 P.M. to 4:30 P.M., the Administrator and Regional Director of Operations conducted a mandatory staff meeting with 56 staff in attendance. The content of the education included the abuse policy, the definitions of abuse, reinforcement of the Administrator being the abuse coordinator and his contact information was provided. Nine employees (three agency and six facility staff), who were assigned to work night shift and who were not present at the meeting were educated prior to their shift beginning. A plan for the remaining 24 staff to be educated prior to the start of their next shift was developed. · Beginning 12/13/17, the facility will provide written abuse education materials to all agency staff working in the building. · On 12/13/17, statements from staff, including STNA #59, RN #18, STNA #36, STNA #89 and STNA #78 were obtained regarding observations of and/or any knowledge of incidents of abuse by STNA #100 toward Resident #7 or any other resident. · On 12/13/17, a plan for the Administrator to log all allegations of abuse, neglect, misappropriation and communicate initial and final reports to the Director of Clinical Services and/or the Regional Director of Operations for all allegations of abuse will be completed. The Director of Clinical Services or Regional Director of Operations would monitor for compliance of reporting through the Self-Reported Incident Log weekly for two months and then monthly for an indefinite time period. The results will be reviewed with monthly performance improvement to continue focus for quality improvement measures. · On 12/13/17, the facility initiated a system that all new admissions beginning on 12/13/17 (for an indefinite time period) would be interviewed by the Social Services Director/designee during the resident's initial admission care conference regarding situations of abuse. The Administrator will follow up with any identified concerns. · Beginning 12/13/17, guardian angel rounds completed weekly will specifically ask questions regarding abuse/neglect/misappropriation. The outcome of the rounds will be discussed during daily Interdisciplinary Team Meetings with any concerns being immediately reported and investigated for an indefinite time period. · Beginning 12/13/17, the Administrator will utilize an Abuse Event Checklist, Alleged Abuse, Neglect and Exploitation Investigation Worksheet to ensure the investigation process was initiated and completed thoroughly. The Administrator was to sign completion of investigations upon validation of completion. · Beginning 12/13/17, a plan for the Administrator, Director of Clinical Services and/or Regional Director of Operations to monitor the Investigation procedure through use of a self-reported incident log for three months with review at the performance improvement meeting monthly to continue focus for quality improvement measures as indicated. · Between 12/11/17 and 12/13/17, interview with Agency LPN #127, STNA 78, STNA #STNA #59, STNA #99, STNA #93, Housekeeper #3 revealed they were knowledgeable of the facility abuse policy and reporting requirements for abuse. Although the Immediate Jeopardy was removed on 12/13/17, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) related to ongoing staff education regarding the facility abuse policy, on-going random audits, resident/family interviews, monitoring to ensure continued resident safety and provision of residents with an opportunity to express concerns. Findings include: 1. Record review revealed Resident #158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission assessment, dated 11/23/17 revealed the resident was alert and oriented, did not have skin alterations to her buttocks and was continent of bowel. At the time of admission, the resident had an indwelling catheter. Review of the admission pressure ulcer risk assessment revealed the resident was at risk for pressure ulcer development. Review of a plan of care for Activities of Daily Living (ADL) care performance deficit dated 11/27/17, revealed the resident required extensive assistance of two staff members with turning and repositioning in bed and toilet use. Review of the nursing progress note, dated 11/23/17 at 1:41 A.M., revealed the resident was continent of bowel. Review of a nursing progress note dated 12/01/17 at 1:54 P.M., revealed Resident #158 had excoriation (beefy, red denuded skin) to the buttocks with new orders to apply a foam dressing to the buttocks daily. The medical record did not contain further documentation related to the cause of the excoriation or a physician's orders [REDACTED]. During an interview with Resident #158 on 12/05/17 at 11:54 A.M., and a follow up interview on 12/06/17 at 3:00 P.M., the resident shared she had concerns related to the facility staffing and an incident that had recently occurred. The resident stated she was aware of when she needed to use the bathroom to move her bowels. The resident stated a few days prior she had to move her bowels and was unable to activate her call light due to the placement of the call light and the light being wrapped around her right arm. The resident stated the door to her room was closed and since she was unable to reach her call light, she started to yell out. She stated she waited and waited, however, no staff came. The resident stated because no one came, she laid in feces all night. The resident stated this caused her skin to breakdown and she was very sore. The resident stated she considered what the staff did to her was abuse and stated she had shared this concern with the staff at the time it occurred. The resident said she also told her husband, when he came in that morning and he immediately shared the concerns with the Administrator. Further interview revealed by the time she was discovered the following morning, she was crying and upset because she felt scared and felt no one was there to care for her. The resident stated the STNA, STNA #83, who failed to answer calls for help and help her to use the bathroom had continued to provide care to her since the incident. On 12/06/17 at 4:30 P.M., interview with the Administrator revealed he was aware of the above incident but thought it was a customer service issue and not an issue of abuse or neglect. At the time of the interview, the Administrator was unable to provide evidence of a thorough investigation including a statement from the resident, statements from any other residents regarding the care they had received the same night, statements from the staff working at the time of the incident or statements from the staff who had knowledge or involvement in the incident. The Administrator also failed to provide evidence the facility investigated the staffing level in the facility at the time of the incident to ensure adequate staff was deployed to meet the resident's needs. On 12/06/17, the Administrator submitted a self-reported incident related to an allegation of neglect/mistreatment/abuse involving Resident #158. The initial reporting revealed the resident alleged staff left her lay in feces all night. The effect noted to the resident indicated the resident was upset that she was not changed for her incontinent episode during the night. On 12/07/17 at 2:00 P.M., interview with STNA #207 revealed she and STNA #61 had provided catheter care and incontinence care to Resident #158 on the morning of 11/30/17. STNA #61 stated the resident was incontinent of a large amount of stool. She believed it was evident, based on the amount of stool present and the condition of the resident's buttocks, the resident had not been changed in a while. On 12/07/17 at 2:10 P.M., interview with STNA #61 revealed she came in to work on 11/30/17 to work day shift (which started at 7:00 A.M.). STNA #61 stated upon her arrival to the unit, she began to check on the residents before breakfast. As she neared the resident's room, she found the door was closed. She entered the resident's room at approximately 7:15 A.M. and found the resident crying and upset. The resident had been incontinent of a large amount of stool and the stool was observed dried to her skin. STNA #61 stated the resident's buttocks were very red and the resident informed her she had not been checked all night. The STNA added, the resident's call light was a soft touch call light (a call light pad about four inches in diameter that is used for resident's who have difficulty pressing a call light button) noted to be on the resident's right side, under her right arm. The STNA stated the light had left an indentation in the resident's skin. STNA #61 shared the resident was unable to move her right arm much and needed the call light on her left side. STNA #61 stated she required help to change the resident and STNA #207 assisted her with the resident's incontinence care. STNA #61 revealed there had not been enough staff working on night shift. On 12/08/17 at 11:50 A.M,. interview with STNA #61 verified the resident's buttocks were red and starting to open. STNA #61 shared she reported the skin alteration to the nurse but was unable to recall the nurse working. Lastly, STNA #61 verified STNA #83 was responsible for the unit at the time of the alleged incident. On 12/07/17 at 2:20 P.M., interview with Licensed Practical Nurse (LPN) #27 revealed she was filling in for the facility wound nurse. LPN #27 stated on 12/01/17, she was assessing Resident #158's skin and observed excoriation to the bilateral buttocks. LPN #27 revealed the resident had reported to her that she had developed the skin issues due to staff leaving her lay in poop. LPN #27 stated being incontinent and not being changed would cause excoriation to the skin. LPN #27 stated she informed the Administrator of the resident's statement at the time it was made to her. An additional interview on 12/08/17 at 8:45 A.M., revealed the incident occurred the day before the skin assessment was completed and she was unaware of the skin alteration until she observed the concern. Review of the staffing schedules revealed following the above identified concern, STNA #83 continued to work and provide resident care on 12/03/17. On 12/07/17 at 2:30 P.M.,RN #5 was observed providing wound care to Resident #158. The resident was assessed to have a 1.8 centimeter (cm) in length by 1.0 cm width open area to the left buttock and a 7.0 cm in length by 6.3 cm width reddened area to the left buttock. The area to the left buttock had bright red drainage. At 2:45 P.M., interview with RN #5 revealed the areas to the buttocks would be considered excoriation. On 12/08/17 at 9:30 A.M., interview with Resident #158's spouse revealed he spoke with the administrator after his wife informed him she laid in feces all night and no one checked on her or changed her soiled clothing. The resident's husband verified he believed Resident #158 experienced skin break down due to not being provided timely incontinence care. On 12/08/17 at 2:16 P.M., interview with STNA #83 revealed she was working night shift (11:00 P.M. to 7:00 A.M.) on 11/29/17 on the 300 and 400 unit, which was the first day she was not in orientation. STNA #83 stated she received orientation on two midnight shifts on the 300 and 400 units and Resident #158 was a new resident to STNA #83 on 11/29/17. She stated she did not have access to the facility's computerized system and had asked the previous shift to document which residents required checking and changing throughout the night and Resident #158 was not marked on the list of residents who would require changing due to incontinence. STNA #83 stated she had not provided care to Resident #83 because she did not ring her call light and she did not enter the resident's room after she changed the trash cans around 1:00 A.M. Further interview revealed she did not hear the resident yelling out through the night but this might have been because she was working on both 400 and 300 units. The STNA shared there was a nurse on the unit, but the nurse did not assist her with providing any direct resident care. The STNA indicated she worked beginning 12/07/17 from 11:00 P.M. to 7:00 A.M. (on 12/08/17) and after her shift, she was notified she was being suspended pending the outcome of an investigation related to the allegation of abuse against Resident #158. The STNA stated she believed the facility was short staffed and the incident that occurred with Resident #158 was a direct result of there not being enough staff. The STNA stated this in addition to the lack of training she received on hire and the lack of knowledge of the residents she was assigned to care for also contributed to the incident. 2. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's cognition was assessed to be moderately impaired. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], indicated the resident was dependent on staff for personal hygiene, locomotion, transfers and required extensive assist from staff with bed mobility, dressing, eating, and toilet use. The resident did not have any behavior issues or rejection of care. Resident #7 was always incontinent of bowel and bladder. The medical record revealed no evidence of bruising. Review of a facility statement of events, contained in an administrative file dated 11/20/17 to 11/23/17, revealed housekeeping staff found unflushed urine and feces in Resident #7's toilet which was reported to the nurse. During a facility investigation, Resident #7 reported STNA #100 had used his toilet and he told him not to. The resident stated STNA #100 told him to go to sleep and not to worry about it. A statement from STNA #57 verified STNA #100 worked on the resident's unit between 11/20/17 and 11/23/17. A statement from STNA #100 denied the allegation. However, because of the incident, the Administrator instructed STNA #100 not to enter Resident #7's room in the future. There was no evidence to ensure how staff, including STNA #100 were made aware of this or evidence the facility followed up with Resident #7 following the incident. On 12/05/17 at 11:23 A.M., during an interview with Resident #7, the resident was asked if he had ever been abused or mistreated by staff. The resident shared an incident that occurred the previous week in which STNA #100 had held him down when he requested to talk to the nurse. When the resident would not tell the STNA why he wanted the nurse the STNA held both arms down and said No, you will tell me what you want. The resident reported the STNA had caused bruising to his arms when he held him down and proceeded to show the surveyor the bruising. The resident voiced he was afraid of STNA #7 and indicated he had reported the incident to the Administrator at the time it had occurred. On 12/05/17 at 11:52 A.M., interview with the Administrator revealed he was not aware of the physical abuse allegation last week. The surveyor shared the information provided by Resident #7 as noted above. The Administrator verified STNA #100 was not permitted in Resident #7's room due to incident regarding the resident's toilet. On 12/05/17 at 5:20 P.M., interview and observation of Resident #7 with Licensed Practical Nurse (LPN) #36 revealed Resident #7 had multiple bruises on his right arm in various healing stages. LPN #36 revealed there were no skin alteration sheets for the bruising on the treatment administration record (TAR) and no nursing progress notes to identify when the bruises were first noted or what the bruises were from. On 12/05/17 at 6:06 P.M., interview with STNA #100 revealed Resident #7 had reported him for mental abuse a few weeks ago. He alleged STNA #100 used his toilet and did not flush. STNA #100 verified he was suspended a day and half pending the investigation. He denied he did it and was unaware of the resident making any other allegations of abuse. He denied that he had ever forcibly held down the resident against his will or any other residents and denied seeing any other employee do the same. On 12/06/17 at 8:43 A.M., interview with the Administrator revealed he had not started any type of investigation related to the allegation made by Resident #7 of STNA #100 physically abusing him one day last week and verified even after discussing the concern on 12/05/17 at 11:53 A.M., STNA #100 worked on 12/05/17 during the 3:00 P.M. to 11:00 P.M. shift providing care for Resident #7 and all the residents on the South unit. The Administrator stated STNA #100 was not supposed to work on South unit, effective 11/21/17 (from the previous incident with Resident #7 as noted above), however due to staff shortage he had no other choice. On 12/06/17 at 2:55 P.M., interview and observation of Resident #7 with Licensed Practical Nurse (LPN) #101 revealed the resident reported STNA #100 held him down causing bruises on his arms a week ago. The resident reported he told STNA #100 he wanted to see a nurse and STNA #100 replied No, you can tell me. The resident responded no, I want the nurse and STNA #100 repeated No, you will talk to me. Resident #7 indicated he was afraid of STNA #100. The red bruised areas on the right arm had the appearance of fingermarks near the right elbow and a red bruised area near the left elbow. LPN #101 reported she would write a statement regarding the interview and observation. She verified there was no documentation in the medical record regarding the bruising. On 12/06/17 at 3:30 P.M., interview and observation of Resident #7 with the Administrator and Registered Nurse (RN) #5 revealed Resident #7 had marks on his right arm (near the elbow) that had the appearance of fingermarks and the left arm had a large red bruised area in the same area as the right. Resident #7 reported STNA #100 held him down causing the bruising and he was afraid of STNA #7. On 12/06/17 at 3:48 P.M., interview with Administrator confirmed the areas on Resident #7's arms appeared suspicious. On 12/06/17 at 4:51 P.M., interview with STNA #207 revealed on 11/21/17 she received an e-mail not to schedule STNA #100 on the South unit. STNA #207 revealed she had to schedule STNA #100 to work on the South unit on 11/30/17, 12/01/17, 12/04/17, and 12/05/17 due to staffing shortage. On 12/07/17 at 8:38 A.M., interview with DON confirmed Resident #7 allegations of physical abuse and the markings on his arms corroborated the allegation of abuse. The DON reported she was not aware of the abuse allegation until yesterday (12/06/17). On 12/07/17 at 10:27 A.M., interview with Administrator revealed no self-reported incident (SRI) related to this incident had been submitted to the State agency as of this time. On 12/07/17 at 12:55 P.M., interview with the Administrator revealed he had submitted an SRI to the State agency today and would start an investigation. The administrator stated STNA #100 had been suspended and he planned to terminate the STNA's employment. Review of STNA #100's personnel file revealed the STNA was hired on 03/02/17. There was no evidence of a 90-day performance evaluation being completed. Review of the employee's personnel file revealed a history of call-off's, tardiness and a no call no show. As of 12/11/17 at 8:47 A.M., interview with the Administrator verified STNA #100 was not immediately suspended following notification of the allegation of physical abuse on 12/05/17. The Administrator indicated that although the resident told the State surveyor he had reported the incident to him at the time it had occurred, he was not aware of it until the State surveyor shared the concern on 12/05/17. The Administrator verified on 12/08/17, the facility conducted interviews with current residents, asking only Have you recently had any reason to feel unsafe in the facility? After discussing the corrective action taken in regard to resident interviews, the facility provided additional resident interviews, for resident's residing on the South unit, asking, Have you ever experienced abuse in the facility. As of 12/11/17, he had not completed a thorough investigation including statements from other residents or from any staff members in regards to allegations of abuse. On 12/11/17 at 9:23 A.M., interview with the Administrator revealed a skin sweep, completed on 12/07/17, was not comprehensive and did not include any type of assessment or measurements of bruising that was identified to the resident's arms. A follow up skin assessment dated [DATE], also failed to include any type of assessment or measurements of bruising that remained on the resident's arms. Review of the facility abuse, neglect, exploitation and misappropriation of resident property policy, revised 10/27/17, revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of [REDACTED]. A nurse should perform an initial assessment of the resident. The assessment should generally include full body assessment for signs of injury. If a staff member was accused or suspected of Abuse the facility should immediately remove the staff member from the facility and the schedule pending the outcome of the investigation. Facility staff should immediately report all such allegations to the administrator/designee and to the State agency. The investigation of allegation violation will be conducted. 3. Review of the abuse investigation Statement of Events dated 09/08/17, revealed Director of Social Services (DSS) #4 asked Resident #39 if she was aware of any staff speaking inappropriately to residents. Resident #39 stated a certain nurse was always picking on her and was snippy. Resident #39 also stated she heard staff speaking inappropriate to other residents, nurse aides no longer at the facility had been mean to the residents and she was told to mind her own business. Review of Resident #39's statement revealed no documented evidence the allegations of abuse were reported to the Administrator or investigated. Review of the State agency SRI documentation revealed no evidence Resident #39's allegations of abuse had been reported to the state agency. On 11/29/17 at 11:10 A.M., interview with the Director of Nursing (DON) verified Resident #21 was verbally abused and neglected by STNA #1. During the interview the DON verified DSS #4 did not report the allegation of abuse to administration. The allegation had not been reported to the state agency and the allegation had not been investigated. Review of the Abuse, Neglect, Exploitation & Misappropriation of Resident Property policy revised 10/27/17, revealed abuse was not to be tolerated, all alleged violations involving abuse were to be investigated and facility staff was to immediately report all such allegations to the Administrator/designee and to the state agency in accordance with the procedures in the policy.

Based on observations, medical record reviews, review of staffing schedules, review of facility abuse investigations, review of a personnel record, review of the facility abuse policy and procedures, and resident and staff interviews, the facility failed to ensure all allegations of abuse and neglect were timely and thoroughly investigated. The failure to investigate all allegations to determine if actual abuse has occurred and the extent residents are affected and the staff involved, can put residents at risk for continued abuse and serious harm. The facility's failure to thoroughly investigate all allegations of abuse and neglect resulted in Immediate Jeopardy on 11/30/17 when Resident #158 alleged State tested Nursing Assistant (STNA) #83 failed to provide incontinence care to her during the night shift resulting in serious harm as excoriation to her buttocks. STNA #61 entered Resident #158's room at 7:15 A.M. on 11/30/17 when she arrived on duty, found Resident#158 crying and upset with a large amount of stool dried to her skin. The resident's buttocks were observed red and starting to open. Resident #158 informed STNA #61 she had not been checked on by staff all night. The Immediate Jeopardy continued as on 12/05/17 Resident #7 reported to the state surveyor STNA #100 had physically abused him last week. In response to Resident #7 asking to speak to a nurse, STNA#100 held the resident down by both of his arms, bruising the resident. The potential for serious harm existed as after the facility was notified of this incident, STNA #100 continued to provide direct care to the residents until his suspension on 12/06/17. The facility also failed to ensure allegations of abuse alleged by Residents #21 and #39 were thoroughly investigated. This affected four (#7, #21, #39 and #158) residents reviewed for abuse and neglect and had the potential to affect all 59 residents residing in the facility. On 12/07/17 at 12:55 P.M., the Administrator, Regional Director of Nursing and Regional Director of Operations were notified that Immediate Jeopardy began on 11/30/17 when Resident #158 reported an allegation of neglect that was not thoroughly and timely investigated and the STNA continued to provide care. The Immediate Jeopardy continued as of 12/05/17, when Resident #7 reported an allegation of abuse that was not thoroughly investigated and the STNA involved in the incident continued to provide direct care. The Immediate Jeopardy was removed on 12/13/17 when the facility initiated the following corrective actions: · On 12/06/17, the facility initiated an investigation regarding the allegation of abuse made to the state surveyor on 12/05/17 by Resident #7. · On 12/07/17 at 1:28 P.M., the Administrator reported Resident #7's allegation of physical abuse to the State Agency. · On 12/07/17, STNA #100's employment was terminated by the facility. · On 12/06/17, the Administrator reported Resident #83's allegation of neglect to the State Agency. The investigation, which included staff statements, determined the incident occurred as a result of insufficient staff on duty on 11/30/17 at the time of the incident. · On 12/07/17, Unit Manager/Registered Nurse (RN) #20 and Licensed Practical Nurse (LPN) #12 with the assistance of State tested Nursing Assistant (STNA) #11 completed a whole house skin audit, to identify any undocumented skin alterations. Any identified undocumented skin issues were resolved at the time of the audit. · On 12/07/17, Social Service Designee (SSD) #125 initiated a resident questionnaire. 52 residents, identified to be alert and oriented were asked Have you recently had any reason to feel unsafe in the facility. No residents interviewed reported they had felt unsafe. · On 12/07/17, the Director of Clinical Services provided in-service education to the Administrator related to the facility abuse policy and investigation process for complaints or self-reported incidents. · On 12/07/17, RN #20 began in-servicing all facility staff on the current policy and procedure regarding abuse and abuse reporting including the definitions of abuse. A plan for all staff to be in-serviced by 12/08/17 was provided. Any staff not educated by 12/08/17 would be unable to return to work until the in-service was completed. As of 12/08/17, 18 staff members were identified to have not received the in-service training. As of 12/10/17, all staff had received the in-service training either in person or via telephone. · On 12/08/17 and 12/09/17, all interviewable residents were asked, Have you ever experienced abuse while in the facility? These interviews were completed by the Interdisciplinary team/guardian angles during rounds. Staff members conducting the above interviews included the dietary manager, Human Resource Director, Business Office Manager, Activities Director, Environmental Services Supervisor, Medical Records, Minimum Data Set (MDS) Coordinator, Director of Nursing, Admissions Director, Assistant Director of Nursing, Therapy Director and Maintenance Director. As a result of these interviews, no concerns were identified. However, on 12/08/17 Resident #51 reported an allegation of neglect related to care concerns identified on the night shift. As of 12/13/17, the facility was in the process of completing this investigation. · On 12/12/17, Activity Director (AD) #126 conducted a resident council meeting. Residents #42, #26, #24, #36, #39, #257, #3, #27 and #8 present at the meeting were educated related to the facility abuse policy and abuse reporting. Residents who were not present at the meeting were visited by their guardian angel and education was provided one on one regarding the facility abuse policy and reporting. Three residents currently in the hospital will receive the education upon their return. A plan for discussing the facility abuse policy and reporting with family members was initiated to be done on admission and during quarterly care conferences. · On 12/12/17 from 4:00 P.M. to 4:30 P.M., the Administrator and Regional Director of Operations conducted a mandatory staff meeting with 56 staff in attendance. The content of the education included the abuse policy, the definitions of abuse, reinforcement of the Administrator being the abuse coordinator and his contact information was provided. Nine employees (three agency and 6 facility staff), who were assigned to work night shift and who were not present at the meeting were educated prior to their shift beginning. A plan for the remaining 24 staff to be educated prior to the start of their next shift was developed. · Beginning 12/13/17, the facility will provide written abuse education materials to all agency staff working in the building. · On 12/13/17 statements from staff, including STNA #59, RN #18, STNA #36, STNA #89 and STNA #78 were obtained regarding observations of and/or any knowledge of incidents of abuse by STNA #100 toward Resident #7 or any other resident. · On 12/13/17, a plan for the Administrator to log all allegations of abuse, neglect, misappropriation and communicate initial and final reports to the Director of Clinical Services and/or the Regional Director of Operations for all allegations of abuse will be completed. The Director of Clinical Services or Regional Director of Operations would monitor for compliance of reporting through the Self-Reported Incident Log weekly for two months and then monthly for an indefinite time period. The results will be reviewed with monthly performance improvement to continue focus for quality improvement measures. · On 12/13/17, the facility initiated a system that all new admissions beginning on 12/13/17 (for an indefinite time period) would be interviewed by the Social Services Director/designee during the resident's initial admission care conference regarding situations of abuse. The Administrator will follow up with any identified concerns. · Beginning 12/13/17, guardian angel rounds completed weekly will specifically ask questions regarding abuse/neglect/misappropriation. The outcome of the rounds will be discussed during daily Interdisciplinary Team Meetings with any concerns being immediately reported and investigated for an indefinite time period. · Beginning 12/13/17, the Administrator will utilize an Abuse Event Checklist, Alleged Abuse, Neglect and Exploitation Investigation Worksheet to ensure the investigation process was initiated and completed thoroughly. The Administrator was to sign completion of investigations upon validation of completion. · Beginning 12/13/17, a plan for the Administrator, Director of Clinical Services and/or Regional Director of Operations to monitor the Investigation procedure through use of a self-reported incident log for three months with review at the performance improvement meeting monthly to continue focus for quality improvement measures as indicated. · Between 12/11/17 and 12/13/17, interviews with Agency Licensed Practical Nurse (LPN) #127, STNA 78, STNA #STNA #59, STNA #99, STNA #93, Housekeeper #3 revealed they were knowledgeable of the facility abuse policy and reporting requirements for abuse. Although the Immediate Jeopardy was removed on 12/13/17, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) related to ongoing staff education regarding the facility abuse policy, on-going random audits, resident/family interviews, monitoring to ensure continued resident safety and provision of residents with an opportunity to express concerns. Findings include: 1. Record review revealed Resident #158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission assessment, dated 11/23/17, revealed the resident was alert and oriented, did not have skin alterations to her buttocks and was continent of bowel. At the time of admission the resident had an indwelling catheter. Review of the admission pressure ulcer risk assessment revealed the resident was at risk for pressure ulcer development. Review of a plan of care for Activities of Daily Living (ADL) care performance deficit dated 11/27/17, revealed the resident required extensive assistance of two staff members with turning and repositioning in bed and toilet use. Review of the nursing progress note, dated 11/23/17 at 1:41 A.M., revealed the resident was continent of bowel. Review of a nursing progress note, dated 12/01/17 at 1:54 P.M., revealed Resident #158 had excoriation (beefy, red denuded skin) to the buttocks with new orders to apply a foam dressing to the buttocks daily. The medical record did not contain further documentation related to the cause of the excoriation or a physician's orders [REDACTED]. During an interview with Resident #158 on 12/05/17 at 11:54 A.M., and a follow up interview on 12/06/17 at 3:00 P.M., the resident shared she had concerns related to the facility staffing and an incident that had recently occurred. The resident stated she was aware of when she needed to use the bathroom to move her bowels. The resident stated a few days prior she had to move her bowels and was unable to activate her call light due to the placement of the call light and the light being wrapped around her right arm. The resident stated the door to her room was closed and, since she was unable to reach her call light, she started to yell out. She stated she waited and waited, however, no staff came. The resident stated because no one came, she laid in feces all night. The resident stated this caused her skin to break down and she was very sore. The resident stated she considered what the staff did to her was abuse and stated she had shared this concern with the staff at the time it occurred. The resident said she also told her husband when he came in that morning and he immediately shared the concerns with the Administrator. Further interview revealed by the time she was discovered the following morning, she was crying and upset because she felt scared and felt no one was there to care for her. The resident stated the STNA, (#83) who failed to answer calls for help and help her to use the bathroom, had continued to provide care to her since the incident. On 12/06/17 at 4:30 P.M,. interview with the Administrator revealed he was aware of the above incident but thought it was a customer service issue and not an issue of abuse or neglect. At the time of the interview, the Administrator was unable to provide evidence of a thorough investigation, including a statement from the resident, statements from any other residents regarding the care they had received the same night, statements from the staff working at the time of the incident or statements from the staff who had knowledge or involvement in the incident. The Administrator also failed to provide evidence the facility investigated the staffing level in the facility at the time of the incident to ensure adequate staff was present to meet the residents' needs. On 12/06/17, the Administrator submitted a self-reported incident, tracking number 6, related to an allegation of neglect/mistreatment/abuse involving Resident #158. The initial reporting revealed the resident alleged staff left her lay in feces all night. The effect noted to the resident indicated the resident was upset that she was not changed for her incontinent episode during the night. On 12/07/17 at 2:00 P.M., interview with STNA #7 revealed she and STNA #61 had provided catheter care and incontinence care to Resident #158 on the morning of 11/30/17. STNA #61 stated the resident was incontinent of a large amount of stool and believed it was evident, based on the amount of stool present and the condition of the resident's buttocks, the resident had not been changed in a while. On 12/07/17 at 2:10 P.M., interview with STNA #61 revealed she came in to work on 11/30/17 to work day shift (which started at 7:00 A.M.). STNA #61 stated upon her arrival to the unit, she began to check on the residents before breakfast. As she neared the Resident #158's room, she found the door closed. She entered the resident's room at approximately 7:15 A.M., and found the resident crying and upset. Resident #158 had been incontinent of a large amount of stool and the stool was observed dried to her skin. STNA #61 stated the resident's buttocks were very red and the resident informed her she had not been checked all night. The STNA added the resident's call light was a soft touch call light (a call light pad about four inches in diameter that is used for residents who have difficulty pressing a call light button) noted to be on the resident's right side, under her right arm. The STNA stated the light had left an indentation in the resident's skin. STNA #61 shared the resident was unable to move her right arm much and needed the call light on her left side. STNA #61 stated she required help to change the resident and STNA #7 assisted her with the resident's incontinence care. STNA #61 revealed there had not been enough staff working on night shift this shift. On 12/08/17 at 11:50 A.M., interview with STNA #61 verified the resident's buttocks were red and starting to open. STNA #61 shared she reported the skin alteration to the nurse but was unable to recall the nurse working. Lastly, STNA #61 verified STNA #83 was responsible for the unit at the time of the alleged incident. On 12/07/17 at 2:20 P.M., interview with Licensed Practical Nurse (LPN) #27 revealed she was filling in for the facility wound nurse. LPN #27 stated on 12/01/17, she was assessing Resident #158's skin and observed excoriation to both buttocks. LPN #27 revealed the resident had reported to her that she had developed the skin issues due to staff leaving her lay in poop. LPN #27 stated being incontinent and not being changed would cause excoriation to the skin. LPN #27 stated she informed the Administrator of the resident's statement at the time it was made to her. An additional interview on 12/08/17 at 8:45 A.M., revealed the incident occurred the day before the skin assessment was completed and she was unaware of the skin alteration until she observed the concern. Review of the staffing schedules revealed following the above identified concern, STNA #83 continued to work and provide resident care on 12/03/17. On 12/07/17 at 2:30 P.M., RN #5 was observed providing wound care to Resident #158. The resident was assessed to have a 1.8 centimeter (cm) in length by 1.0 cm width open area to the left buttock and a seven cm in length by 6.3 cm width reddened area to the left buttock. The area to the left buttock had bright red drainage. At 2:45 P.M., interview with RN #5 revealed the areas to the buttocks would be considered excoriation. On 12/08/17 at 9:30 A.M., interview with Resident #158's spouse revealed he spoke with the administrator after his wife informed him she laid in feces all night and no one checked on her or changed her soiled clothing. The resident's husband verified he believed Resident #158 experienced skin break down due to not being provided timely incontinence care. On 12/08/17 at 2:16 P.M., interview with STNA #83 revealed she was working night shift (11:00 P.M. to 7:00 A.M.) on 11/29/17 on the 300 and 400 unit, which was the first day she was not in orientation. STNA #83 stated she received orientation on two midnight shifts on the 300 and 400 units and Resident #158 was a new resident to STNA #83 on 11/29/17. She stated she did not have access to the facility's computerized system and had asked the previous shift to document which residents required checking and changing throughout the night and Resident #158 was not marked on the list of residents who would require changing due to incontinence. STNA #83 stated she had not provided care to Resident #83 because she did not ring her call light and she did not enter the resident's room after she changed the trash cans around 1:00 A.M. Further interview revealed she did not hear the resident yelling out through the night but this might have been because she was working on both 400 and 300 units. The STNA shared there was a nurse on the unit, but the nurse did not assist her with providing any direct resident care. The STNA indicated she worked beginning 12/07/17 from 11:00 P.M. to 7:00 A.M. (on 12/08/17) and after her shift, she was notified she was being suspended pending the outcome of an investigation related to the allegation of abuse against Resident #158. The STNA stated she believed the facility was short staffed and the incident that occurred with Resident #158 was a direct result of there not being enough staff. The STNA stated this in addition to the lack of training she received on hire and the lack of knowledge of the residents she was assigned to care for also contributed to the incident. Review of the facility abuse, neglect, exploitation and misappropriation of resident property policy, revised 10/27/17, revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of [REDACTED]. Facility staff should immediately report all such allegations to the Administrator/designee and to the State agency. The policy defined neglect as the failure of the facility, it's employees, or facility service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress. Prevention of abuse/neglect would include the deployment of staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs. 2. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's cognition was assessed to be moderately impaired. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], indicated the resident was dependent on staff for personal hygiene, locomotion, transfers and required extensive assist from staff with bed mobility, dressing, eating and toilet use. The resident did not have any physical, verbal, or any other behavioral symptoms or rejection of care. The resident was noted to be always incontinent of bowel and bladder. The paper and electronic medical record indicated no evidence of bruising. Review of a facility statement of events, contained in an administrative file, dated 11/20/17 to 11/23/17, revealed housekeeping staff found unflushed urine and feces in Resident #7's toilet which was reported to the nurse. During a facility investigation, Resident #7 reported STNA #100 had used his toilet and he told him not to. The resident stated STNA #100 told him to go to sleep and not to worry about it. A statement from STNA #57 verified STNA #100 worked on the resident's unit between 11/20/17 and 11/23/17. A statement from STNA #100 denied the allegation. However, because of the incident, the Administrator instructed STNA #100 not to enter Resident #7's room in the future. There was no evidence to ensure how staff, including STNA #100 were made aware of this or evidence the facility followed up with Resident #7 following the incident. On 12/05/17 at 11:23 A.M., during an interview with Resident #7, the resident was asked if he had ever been abused or mistreated by staff. The resident shared an incident that occurred in which STNA #100 had held him down last week when he requested to talk to the nurse. When the resident would not tell the STNA why he wanted the nurse, the STNA held both arms down and said No, you will tell me what you want. The resident reported the STNA had caused bruising to his arms when he held him down and proceeded to show the surveyor the bruising. The resident voiced he was afraid of STNA #100 and indicated he had reported the incident to the Administrator at the time it had occurred. On 12/05/17 at 11:52 A.M., interview with the Administrator revealed he was not aware of the physical abuse allegation last week. The surveyor shared the information provided by Resident #7 as noted above. The Administrator verified STNA #100 was not permitted in Resident #7's room due to the incident regarding the resident's toilet. On 12/05/17 at 5:20 P.M., interview and observation of Resident #7 with LPN #36 revealed Resident #7 had multiple bruises on his right arm in various healing stages. LPN #36 revealed there were no skin alteration sheets for the bruising on the treatment administration record (TAR) and no nursing progress notes to identify when the bruises were first noted or what the bruises were from. On 12/05/17 at 6:06 P.M., interview with STNA #100 revealed Resident #7 had reported him for mental abuse a few weeks ago. He alleged STNA #100 used his toilet and did not flush. STNA #100 verified he was suspended a day and half pending the investigation. He denied he did it and was unaware of the resident making any other allegations of abuse. He denied that he had ever forcibly held down the resident against his will or any other residents and denied seeing any other employee do the same. On 12/06/17 at 8:43 A.M., interview with the Administrator revealed he had not started any type of investigation related to the allegation made by Resident #7 of STNA #100 physically abusing him one day last week and verified even after discussing the concern on 12/05/17 at 11:53 A.M., STNA #100 worked on 12/05/17 during the 3:00 P.M. to 11:00 P.M. shift providing care for Resident #7 and all the residents on the South unit. The Administrator stated STNA #100 was not supposed to work on the South unit, effective 11/21/17 (from the previous incident with Resident #7 as noted above), however due to staff shortage he had no other choice. On 12/06/17 at 2:55 P.M., interview and observation of Resident #7 with LPN #101 revealed the resident reported STNA #100 held him down causing bruises on his arms a week ago. The resident reported he told STNA #100 he wanted to see a nurse and STNA #100 replied No, you can tell me. The resident responded no, I want the nurse and STNA #100 repeated No, you will talk to me. Resident #7 indicated he was afraid of STNA #100. The red bruised areas on the right arm had the appearance of finger marks near the right elbow and a red bruised area near the left elbow. LPN #101 reported she would write a statement regarding the interview and observation. She verified there was not documentation in the medical record regarding the bruising. On 12/06/17 at 3:30 P.M., interview and observation of Resident #7 with the Administrator and Registered Nurse (RN) #5 revealed Resident #7 had marks on his right arm (near elbow) that have the appearance of finger marks and the left arm had a large red bruised area in the same area as the right. The resident reported STNA #100 held him down causing the bruising and he was afraid of STNA #100. On 12/06/17 at 3:48 P.M., interview with Administrator confirmed the areas on Resident #7's arms appeared suspicious. On 12/06/17 at 4:51 P.M., interview with STNA #7 revealed on 11/21/17 she received an e-mail not to schedule STNA #100 on the South unit. STNA #7 revealed she had to schedule STNA #100 to work on the South unit on 11/30/17, 12/01/17, 12/04/17 and 12/05/17 due to the staffing shortage. On 12/07/17 at 8:38 A.M., interview with the Director of Nursing (DON) confirmed Resident #7's allegations of physical abuse and the markings on his arms corroborated the allegation of abuse. The DON reported she was not aware of the abuse allegation until yesterday (12/06/17). On 12/07/17 at 10:27 A.M., interview with Administrator revealed no self-reported incident (SRI) related to this incident had been submitted to the State agency as of this time. On 12/07/17 at 12:55 P.M., interview with the Administrator revealed he had submitted an SRI to the State agency today and would start an investigation. The administrator stated STNA #100 had been suspended and he planned to terminate the STNA's employment. Review of LPN #101's statement of events, dated 12/06/17 at 2:55 P.M., revealed Resident #7 stated STNA #100 held him down causing bruises on his arms. Resident #7 reported he told STNA #100 he wanted to talk to the nurse and STNA #100 said No, you can talk to me. Resident said No, I want the nurse and STNA #100 repeated No, you will talk to me. Resident #7 reported he was afraid. Review of STNA #100's personnel file revealed the STNA was hired on 03/02/17. There was no evidence of a 90-day performance evaluation being completed. Review of the employee's personnel file revealed a history of call-off's, tardiness and a no call/no show. As of 12/11/17 at 8:47 A.M., interview with the Administrator verified STNA #100 was not immediately suspended following notification of the allegation of physical abuse on 12/05/17. The Administrator again indicated that although the resident told the State surveyor he had reported the incident to him at the time it had occurred, he was not aware of it until the State surveyor shared the concern on 12/05/17. The Administrator verified on 12/08/17, the facility conducted interviews with current residents, asking only Have you recently had any reason to feel unsafe in the facility? After discussing the corrective action taken in regard to resident interviews, the facility provided additional resident interviews for residents residing on the South unit, asking, Have you ever experienced abuse in the facility. As of 12/11/17, he had not completed a thorough investigation including statements from other residents or from any staff members in regard to allegations of abuse. On 12/11/17 at 9:23 A.M., interview with the Administrator revealed a skin sweep, completed on 12/07/17, was not comprehensive and did not include any type of assessment or measurements of bruising that was identified to the resident's arms. A follow up skin assessment dated [DATE] also failed to include any type of assessment or measurements of bruising that remained on the resident's arms. Review of the facility abuse, neglect, exploitation and misappropriation of resident property policy, revised 10/27/17, revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of [REDACTED]. A nurse should perform an initial assessment of the resident. The assessment should generally include full body assessment for signs of injury. If a staff member was accused or suspected of Abuse, the facility should immediately remove the staff member from the facility and the schedule pending the outcome of the investigation. Facility staff should immediately report all such allegations to the administrator/designee and to the State agency. 3. Medical record review revealed Resident #21 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS 3.0 assessment dated [DATE], and the quarterly MDS 3.0 assessment dated [DATE], revealed Resident #21 was cognitively intact for daily decision-making and was always continent of urine. Review of the Self-Reported Incident (SRI) submitted 09/05/17, revealed on 09/04/17, Resident #21 reported that an STNA had been mean to her and called her disgusting. Staff on duty at the time of the incident were interviewed and verified STNA #1 talked to the resident inappropriately, refused to toilet the resident and turned off the call light without tending to the resident's needs. Review of the facility investigation revealed no investigation of the resident's continence status due to not being toileted timely, no evidence of the timeframe when the abuse occurred or what time the abuse was reported to the charge nurse and the administrator. On 11/29/17 at 11:10 A.M., interview with the DON stated Resident #21's continence status was not documented when the resident was toileted after STNA #1 neglected the resident. Between 12:30 P.M. and 12:45 P.M., interview with the DON stated the resident was normally incontinent of urine when she activates her call light to be toileted but verified this was not addressed in the investigation. The DON verified the previous administrator did not complete a thorough investigation of Resident #21's substantiated abuse. Review of the facility abuse investigation dated 09/04/17 through 09/08/17, revealed two random residents were interviewed to determine if others were affected by abuse. Review of the abuse investigation Statement of Events dated 09/08/17, revealed Director of Social Services (DSS) #4 asked Resident #39 if she was aware of any staff speaking inappropriately to residents. Resident #39 stated a certain nurse was always picking on her and was snippy. Resident #39 also stated she heard staff speaking inappropriately to other residents, nurse aides no longer at the facility had been mean to the residents,and she was told to mind her own business. Review of Resident #39's statement revealed no documented evidence the allegations of abuse were reported to the Administrator or investigated. Review of the state agency Self-Reported Incidents revealed no evidence Resident #39's allegations of abuse from an interview conducted on 09/08/17, by DSS #4 had been reported to the state agency. On 11/29/17 at 11:10 A.M., interview with the DON verified DSS #4 interviewed two random residents after a substantiated abuse allegation on 09/04/17. The DON verified one of the two residents interviewed reported an allegation of abuse. The DON stated DSS #4 no longer worked at the facility, verified DSS #4 did not report the allegation of abuse, the allegation had not been reported to the State agency and the allegation had not been investigated. Review of (TRUNCATED)

Based on observations, medical record reviews, review of staffing schedules, review of resident council minutes, review of staffing, restorative and abuse policy and procedures, and resident, family, and staff interviews, the facility failed to provide sufficient and adequate licensed nursing and direct care staff to ensure all residents received the necessary care and services to attain their highest level of well-being. This lack of sufficient and adequate staff resulted in staff being permitted to work following allegations of physical abuse and neglect and a lack of timely and appropriate personal and incontinence care. This resulted in Immediate Jeopardy for Resident #7 when State tested Nursing Assistant (STNA) #100 who had a current allegation of abuse and neglect was assigned to work the unit due to the staff shortage. This resulted in Immediate Jeopardy for Resident #158 when STNA #83 failed to provide incontinence care during the night shift due to a lack of staff resulting in excoriation to her buttocks. This resulted in Immediate Jeopardy for Resident #5 who was not provided restorative services to prevent a decline in ambulation status due to a lack of staff to provide services. The facility also failed to ensure resident, staff and family staffing concerns were addressed and resolved, failed to deploy staff to implement an effective restorative nursing program and failed to ensure sufficient staff were working to respond to the front entrance door alarm in a timely manner. This lack of sufficient staffing resulted in Immediate Jeopardy for all 59 residents residing in the facility. On 12/07/17 at 12:55 P.M. the Administrator, Regional Director of Nursing, and Regional Director of Operations were notified Immediate Jeopardy began on 11/30/17, when due to short staffing, STNA #100 who had a pending abuse/neglect allegation worked on the South unit providing care for Resident #7 and the other residents in the building. The Immediate Jeopardy continued on 11/30/17, when STNA #83 failed to provide incontinence care to Resident #158 during the night shift resulting in excoriation to the resident's buttocks. Actual harm occurred when STNA #61 entered Resident #158's room on 11/30/17 at 7:15 A.M., when she arrived on duty, found the resident crying and upset and identified the resident had a large amount of stool that was dried to her skin. The resident's buttocks were observed to be red and starting to open. Resident #158 informed STNA #61 she had not been checked on by staff all night. The Immediate Jeopardy continued on 12/04/17 at 5:25 A.M., when no staff responded to the door alarm when surveyors entered the building. On 12/04/17 at 5:30 A.M., a resident responded to the door alarm and reset the door alarm. No staff were observed to respond to the alarm prior to the resident resetting it. At the time of this observation, four staff were located in the building and multiple call lights were observed activated until 6:10 A.M. From 6:10 A.M. to 6:20 A.M., STNA #65 was observed to enter resident rooms to turn off the call lights but not provide any care. The Immediate Jeopardy continued on 12/04/17, with actual harm when Resident #5 had a decline in ambulation status due to the lack of staffing to provide restorative services. The facility also failed to maintain adequate levels of nursing staff to ensure Resident #5 was provided timely toileting assistance to prevent incontinence. The Immediate Jeopardy continued 12/05/17, when Resident #7 reported to the State surveyor he had been physically abused by STNA #100, who had held him down by his bilateral arms in bed, the week prior, after asking to speak to the nurse. The potential for actual harm occurred, when following notification of the incident, STNA #100 was permitted to continue to provide direct care to all facility residents until he was suspended on 12/06/17. In addition, STNA #100 was not to work on the South unit or provide care to Resident #7, effective 11/21/17, however, due to a lack of available staff to work, the STNA was assigned to care for Resident #7 and to residents on the South unit between 11/21/17 and 12/05/17. The Immediate Jeopardy was removed on 12/13/17 when the facility implemented the following corrective action: · On 11/27/17, a new unit manager, Registered Nurse (RN) #20 was hired. · On 11/29/17, the facility implemented sign-on bonuses for RNs and Licensed Practical Nurses (LPNs). Bonuses for perfect attendance pick up shift bonuses and referral bonuses were also implemented. · On 12/01/17, the Administrator contacted all local colleges to inquire about upcoming job fairs with plans to attend future fairs for recruitment of staff. · From 12/07/17 through 12/12/17, the Administrator communicated with an outside agency and implemented the use of agency licensed nursing and STNA staff to provide coverage for an indefinite period of time. Agency staff will be scheduled for two week intervals for all three shifts. · On 12/07/17, Unit Manager/RN #20 and LPN #12 with the assistance of STNA #11 completed a whole house skin audit, to identify any undocumented skin alterations. Any identified undocumented skin issues were resolved at the time of the audit. · On 12/07/17, Social Service Designee (SSD) #125 initiated a resident questionnaire. Fifty Two residents, identified to be alert and oriented were asked Do you feel there is adequate staffing? 20 residents indicated they did not believe the facility had enough staff. · On 12/08/17, approval by the Corporate Administrator to use contracted interim administrative nursing unit managers was given. · On 12/08/17, the facility implemented the use of Hospitality Aides to be added to the schedule for night shift to provide non-clinical support. · On 12/11/17, a full time staffing/schedule coordinator (STNA #207) was hired to focus solely on staffing and handling call offs. The STNA assumed this role on 12/11/17. · On 12/11/17, the Administrator communicated with a second outside agency and implemented agency licensed nursing and STNA staff to provide coverage for an indefinite period of time. · On 12/11/17, the Administrator contacted a recruiting firm to contract with, locate and hire full time LPNs, RNs and STNA staff, a contract was signed on this date to do staffing on the facility behalf, as well as two national companies. A contract with a second recruiting agency was signed on 12/13/17. · Between 12/07/17 and 12/12/17, the facility provided evidence of new employee's being hired. This included licensed staff and STNA staff. Hire dates were noted to be between 12/13/17 and 12/20/17. As of 12/13/17, the facility identified five full time employees and one part time employee had been hired. · Between 12/07/17 and 12/12/17, the facility identified and reached out to previous reputable employees to gauge interest in returning to the facility and offering positions if they were. · On 12/12/17, the facility spoke with a local college about sending hospitality aides to STNA training classes, beginning on 01/15/17. · On 12/12/17, the facility received confirmations from staffing agencies with staff schedules through 12/22/17. · On 12/12/17, confirmation was received for contracted unit managerial staff from a staffing agency beginning on 12/18/17. · On 12/12/17, the facility identified staffing would be provided at 3.1 hours per resident per day (above the minimum State requirement of 2.5 hours per resident per day). This would include four nurses and five STNAs scheduled on the day and afternoon shift which would be increased as needed based on acuity/census. Three nurses and four STNAs scheduled on the night shift which would be increased as needed based on acuity/census. The current facility census was 59. · On 12/12/17, Activity Director (AD) #126 conducted a resident council meeting. Residents #42, #26, #24, #36, #39, #257, #3, #27 and #8 present at the meeting were educated related to the facility staffing ratios, planned staff being scheduled on each shift, the facility call off policy and presence of management staff onsite in the facility. The residents were educated to notify managers and/or the Administrator if they felt staffing was not adequate. Three residents currently in the hospital will receive the education upon their return. A plan for discussing the facility staffing with family members was initiated to be done on admission and during quarterly care conferences. · On 12/12/17 from 4:00 P.M. to 4:30 P.M. ,the Administrator and Regional Director of Operations conducted a mandatory staff meeting with 56 staff in attendance. The content of the education included a review of the facility call off policy, staff ratios currently required in the facility, the number of staff being assigned to each shift, the facility call off procedure and staff responsibilities for providing care and supervision to residents. Nine employees (three agency and 6 facility staff), who were assigned to work night shift and who were not present at the meeting were educated prior to their shift beginning. A plan for the remaining 24 staff to be educated prior to the start of their next shift was developed. · On 12/12/17 at 9:30 P.M,. the Director of Nursing provided education to three agency licensed nurses (LPN #128, #129 and #130) assigned to work during the night shift on 12/12/17. The education indicated that due to call offs on the staffing schedule, the licensed nurses would be responsible to provide primary care with the STNAs to residents. This included answering call lights, providing incontinence care and any other duties required as an STNA. · Beginning on 12/13/17, the facility indicated all employees would be provided an additional job description for reference which included requirements for job and expectations related to care. A plan to provide education to all staff on their job description will be completed by 12/20/17. · On 12/13/17, job descriptions for clinicians were posted at the nurse's stations for additional reference. · Beginning 12/13/17, a monitoring tool was developed for residents to be monitored a minimum of weekly by the interdisciplinary team and audited through the facility Quality Assurance process. This tool includes observing for turning and repositioning, grooming, call light response or toileting needs. This monitoring tool will be utilized for an indefinite time period. · Beginning 12/13/17, direct nursing staff will conduct medication and treatment administration audits during shift change to ensure medications were administered and treatments were completed as ordered. Any concerns will be reported to the Director of Nursing/designee. These audits will be utilized for a two month time period and if no concerns are identified will be done as needed. · Beginning 12/13/17, the Director of Nursing/designee will complete weekly chart audits to be done for up to 10 residents to ensure medications were administered and documented properly. · Beginning 12/13/17, the Administrator or Director of Nursing will offer to attend resident council meetings so resident concerns can be addressed proactively. · Beginning 12/13/17, a Customer Satisfaction Survey will be implemented for all residents. The surveys will be distributed in house by the Interdisciplinary Team Guardian Angel program. For residents who are non-interviewable, the survey will be given to family/responsible parties as applicable. The survey contained questions related to nursing services and call light response as well as a rating of the overall nursing care received. The survey will be completed quarterly for long term care residents and prior to discharge for short term/rehab residents for an indefinite time period. · Beginning 12/13/17, the facility will be implementing an employee recognition program to acknowledge staff providing consistent quality of care for facility residents. · Between 12/12/17 and 12/13/17, interview with Agency LPN #127, STNA #78, STNA #59, STNA #99, STNA #93 and Housekeeper #3 revealed they were knowledgeable of the facility staffing requirements and knowledgeable about what to do if they believed the facility was short staffed. · Beginning 12/18/17, the facility will implement a day shift RN unit manager and a night shift RN unit manager provided from a staffing agency until these positions can be filled in house for the facility. The unit manager will be responsible for the identification of and/or addressing any staffing issues. Between 12/13/17 and 12/18/17 the Director of Clinical Services, Regional Director of Operations, a consultant RN and DON staff from sister facilities and the Administrator will provide this oversight. · On 12/13/17, upon arrival to the facility at 7:10 A.M., the Regional Director of Operations was observed on the nursing units. Interview with the Director revealed he had worked the previous night shift to ensure adequate staffing was available and resident's call lights were being answered. For the night shift, on the South unit there were two licensed nurses, a hospitality aide, two STNAs plus an additional STNA in orientation from 11:00 P.M. to 4:00 A.M. On the North unit there were two nurses and a third nurse until 5:00 A.M., one STNA and one hospitality aide for the shift. Although the Immediate Jeopardy was removed on 12/13/17, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) related to ongoing staff education regarding the facility staffing, on-going random audits, resident/family interviews, monitoring to ensure continued resident safety and provision of residents with an opportunity to express concerns. Findings include: 1. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's cognition was assessed to be moderately impaired. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], indicated the resident was dependent on staff for personal hygiene, locomotion, transfers and required extensive assist from staff with bed mobility, dressing, eating, and toilet use. The resident did not have any physical, verbal, or any other behavioral symptoms or rejection of care. The resident was noted to be always incontinent of bowel and bladder and did not use the bathroom. The paper and electronic medical record revealed no evidence of bruising to the resident. Review of a facility statement of events, contained in an administrative file dated 11/20/17 to 11/23/17, revealed housekeeping staff found unflushed urine and feces in Resident #7's toilet which was reported to the nurse. During a facility investigation, Resident #7 reported STNA #100 had used his toilet and he told him not to. The resident stated STNA #100 told him to go to sleep and not to worry about it. A statement from STNA #57 verified STNA #100 had worked on the resident's unit between 11/20/17 and 11/23/17. A statement from STNA #100 denied the allegation. However, as a result of the incident, the Administrator instructed STNA #100 not to enter Resident #7's room in the future. There was no evidence to ensure how staff, including STNA #100 were made aware of this or evidence the facility followed up with Resident #7 following the incident. On 12/05/17 at 11:23 A.M., during an interview with Resident #7, the resident was asked if he had ever been abused or mistreated by staff. The resident shared an incident that occurred in which STNA #100 had held him down last week when he requested to talk to the nurse. When the resident would not tell STNA #100 why he wanted the nurse, STNA #100 held both arms down and said No, you will tell me what you want. The resident reported the STNA had caused bruising to his arms when he held him down and proceeded to show the surveyor the bruising. The resident voiced he was afraid of STNA #100 and indicated he had reported the incident to the Administrator. On 12/05/17 at 5:20 P.M., interview and observation of Resident #7 with LPN #36 revealed Resident #7 had multiple bruises on his right arm in various healing stages. LPN #36 revealed there were no skin alteration sheets for the bruising on the treatment administration record (TAR) and no nursing progress notes to identify when the bruises were first noted or what the bruises were from. On 12/06/17 at 8:43 A.M., interview with the Administrator revealed he had not started any type of investigation related to the allegation made by Resident #7 of STNA #100 physically abusing him one day last week and verified even after discussing the concern on 12/05/17 at 11:53 A.M., STNA #100 worked on 12/05/17 during the 3:00 P.M. to 11:00 P.M. shift providing care for Resident #7 and all the residents on the South unit. The Administrator stated STNA #100 was not supposed to work on South unit, (from the previous incident with Resident #7 as noted above), however due to staff shortage he had no other choice. On 12/06/17 at 2:55 P.M., interview with Resident #7 with Licensed Practical Nurse (LPN) #101 present revealed the resident reported STNA #100 held him down causing bruises on his arms a week ago. The resident reported he told STNA #100 he wanted to see a nurse and STNA #100 replied No, you can tell me. The resident responded no, I want the nurse and STNA #100 repeated No, you will talk to me. Resident #7 indicated he was afraid of STNA #100. The resident confirmed the areas on his arm where STNA #100 held him down. LPN #101 reported she would write a statement regarding the interview. On 12/06/17 at 4:51 P.M., interview with STNA #7 revealed on 11/21/17, she received an e-mail not to schedule STNA #100 on the South unit. STNA #7 revealed she had to schedule STNA #100 to work on the South unit on 11/30/17, 12/01/17, 12/04/17, and 12/05/17 due to staffing shortage. On 11/20/17, STNA #100 was assigned to work on the South unit. Review of the daily staffing sheets dated 11/30/17 to 12/06/17, for the South unit revealed STNA #100 worked on the South unit 11/30/17, 12/01/17, 12/04/17, and 12/05/17 due to staffing call off's. On 12/04/17 STNA #100 worked 11:00 P.M. to 4:00 A.M., on South unit by himself. Review of the staffing schedule revealed two additional staff assigned to work at that time, reported off, leaving STNA #100 as the only staff member on the unit during that time period. Review of the facility undated Staffing policy revealed the facility was to provide adequate staffing to meet needed care and services for the resident population on each shift to ensure resident needs and services were met. Licensed Nursing staff were to be available to provide and monitor the delivery of resident care services and STNAs were to be available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan. Review of the facility abuse, neglect, exploitation and misappropriation of resident property policy, revised 10/27/17, revealed it was the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of [REDACTED]. Facility staff should immediately report all such allegations to the administrator/designee and to the State agency. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting in physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods. Prevention of abuse/neglect would include the deployment of staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs. 2. Record review revealed Resident #158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission assessment, dated 11/23/17, revealed the resident was alert and oriented, did not have skin alterations to her buttocks and was continent of bowel. At the time of admission, the resident had an indwelling catheter. Review of the admission pressure ulcer risk assessment revealed the resident was at risk for pressure ulcer development. Review of a plan of care for Activities of Daily Living (ADL) care performance deficit dated 11/27/17, revealed the resident required extensive assistance of two staff members with turning and repositioning in bed and toilet use. Review of the nursing progress note dated 11/23/17 at 1:41 A.M., revealed the resident was continent of bowel. Review of a nursing progress note, dated 12/01/17 at 1:54 P.M., revealed Resident #158 had excoriation (beefy, red denuded skin) to the buttocks with new orders to apply a foam dressing to the buttocks daily. The medical record did not contain further documentation related to the cause of the excoriation or a physician's orders [REDACTED]. During an interview with Resident #158 on 12/05/17 at 11:54 A.M., and a follow up interview on 12/06/17 at 3:00 P.M., the resident shared she had concerns related to the facility staffing and an incident that had recently occurred. The resident stated she was aware of when she needed to use the bathroom to move her bowels. The resident stated a few days prior she had to move her bowels and was unable to activate her call light due to the placement of the call light and the light being wrapped around her right arm. The resident stated the door to her room was closed and since she was unable to reach her call light, she started to yell out. She stated she waited and waited, however, no staff came. The resident stated because no one came, she laid in feces all night. The resident stated this caused her skin to breakdown and she was very sore. The resident stated she considered what the staff did to her was abuse and stated she had shared this concern with the staff at the time it occurred. The resident said she also told her husband, when he came in that morning and he immediately shared the concerns with the Administrator. Further interview revealed by the time she was discovered the following morning, she was crying and upset because she felt scared and felt no one was there to care for her. The resident stated STNA #83, who failed to answer calls for help and help her to use the bathroom had continued to provide care to her since the incident. On 12/06/17 at 4:30 P.M. ,interview with the Administrator revealed he was aware of the above incident but thought it was a customer service issue and not an issue of abuse or neglect. At the time of the interview, the Administrator was unable to provide evidence of a thorough investigation including a statement from the resident, statements from any other residents regarding the care they had received the same night, statements from the staff working at the time of the incident or statements from the staff who had knowledge or involvement in the incident. The Administrator also failed to provide evidence the facility investigated the staffing level in the facility at the time of the incident to ensure adequate staff was deployed to meet the resident's needs. On 12/06/17, the Administrator submitted a self-reported incident, related to an allegation of neglect/mistreatment/abuse involving Resident #158. The initial reporting revealed the resident alleged staff left her lay in feces all night. The effect noted to the resident indicated the resident was upset that she was not changed for her incontinent episode during the night. On 12/07/17 at 2:00 P.M., interview with STNA #7 revealed she and STNA #61 had provided catheter care and incontinence care to Resident #158 on the morning of 11/30/17. STNA #61 stated the resident was incontinent of a large amount of stool and believed it was evident based on the amount of stool present and the condition of the resident's buttocks the resident had not been changed in a while. On 12/07/17 at 2:10 P.M., interview with STNA #61 revealed she came in to work on 11/30/17 to work day shift (which started at 7:00 A.M.). STNA #61 stated upon her arrival to the unit, she began to check on the residents before breakfast. As she neared the resident's room, she found the door was closed. She entered the resident's room at approximately 7:15 A.M. and found the resident crying and upset. The resident had been incontinent of a large amount of stool and the stool was observed dried to her skin. STNA #61 stated the resident's buttocks were very red and the resident informed her she had not been checked all night. The STNA added, the resident's call light was a soft touch call light (a call light pad about four inches in diameter that is used for residents who have difficulty pressing a call light button) noted to be on the residents right side, under her right arm. The STNA stated the light had left an indentation in the resident's skin. STNA #61 shared the resident was unable to move her right arm much and needed the call light on her left side. STNA #61 stated she required help to change the resident and STNA #7 assisted her with the resident's incontinence care. STNA #61 revealed there had not been enough staff working on night shift this shift. On 12/07/17 at 2:20 P.M., interview with Licensed Practical Nurse (LPN) #27 revealed she was filling in for the facility wound nurse. LPN #27 stated on 12/01/17 she was assessing Resident #158's skin and observed excoriation to the bilateral buttocks. LPN #27 revealed the resident had reported to her that she had developed the skin issues due to staff leaving her lay in poop. LPN #27 stated being incontinent and not being changed would cause excoriation to the skin. LPN #27 stated she informed the Administrator of the resident's statement at the time it was made to her. An additional interview with LPN #27 on 12/08/17 at 8:45 A.M., revealed the incident occurred the day before the skin assessment was completed and she was unaware of the skin alteration until she observed the concern. On 12/08/17 at 11:50 A.M., interview with STNA #61 verified the resident's buttocks were red and starting to open. STNA #61 shared she reported the skin alteration to the nurse but was unable to recall the nurse working. Lastly, STNA #61 verified STNA #83 was responsible for the unit at the time of the alleged incident. Review of the staffing schedules revealed following the allegations of neglect, STNA #83 continued to work and provide resident care on 12/03/17. On 12/07/17 at 2:30 P.M., RN #5 was observed providing wound care to Resident #158. The resident was assessed to have a 1.8 centimeter (cm) in length by 1.0 cm width open area to the left buttock and a seven cm in length by 6.3 cm width reddened area to the left buttock. The area to the left buttock had bright red drainage. At 2:45 P.M. interview with RN #5 revealed the areas to the buttocks would be considered excoriation. On 12/08/17 at 9:30 A.M., interview with Resident #158's spouse revealed he spoke with the administrator after his wife informed him she laid in feces all night and no one checked on her or changed her soiled clothing. The resident's husband verified he believed Resident #158 experienced skin break down due to not being provided timely incontinence care. On 12/08/17 at 2:16 P.M., interview with STNA #83 revealed she was working night shift (11:00 P.M. to 7:00 A.M.) on 11/29/17 on the 300 and 400 unit, which was the first day she was not in orientation. STNA #83 stated she received orientation on two midnight shifts on the 300 and 400 units and Resident #158 was a new resident to STNA #83 on 11/29/17. She stated she did not have access to the facility's computerized system and had asked the previous shift to document which residents required checking and changing throughout the night and Resident #158 was not marked on the list of residents who would require changing due to incontinence. STNA #83 stated she had not provided care to Resident #83 because she did not ring her call light and she did not enter the resident's room after she changed the trash cans around 1:00 A.M. Further interview revealed she did not hear the resident yelling out through the night but this might have been because she was working on both 400 and 300 units. The STNA shared there was a nurse on the unit, but the nurse did not assist her with providing any direct resident care. The STNA indicated she worked beginning 12/07/17 from 11:00 P.M. to 7:00 A.M. (on 12/08/17) and after her shift, she was notified she was being suspended pending the outcome of an investigation related to the allegation of abuse against Resident #158. The STNA stated she believed the facility was short staffed and the incident that occurred with Resident #158 was a direct result of there not being enough staff. The STNA stated this in addition to the lack of training she received on hire and the lack of knowledge of the resident's she was assigned to care for also contributed to the incident. Review of the facility undated Staffing policy revealed the facility was to provide adequate staffing to meet needed care and services for the resident population on each shift to ensure resident needs and services were met. Licensed Nursing staff were to be available to provide and monitor the delivery of resident care services and STNAs were to be available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan. 3. Record review revealed Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 assessment dated [DATE], revealed the resident was cognitively intact for daily decision-making, required extensive assist with walking and had received both occupational and physical therapy. Review of the Physical Therapy (PT) Discharge Summary dated 09/13/17, revealed at the time of discharge, the resident was able to walk 125 feet with caregiver assist. Therapy was discontinued due to the resident's insurance approved therapy sessions had been exhausted. The prognosis to maintain the resident's current level of functioning at the time of discharge was considered good with consistent staff follow-through. Discharge recommendations included to encourage ambulation to/from the bathroom with nursing assistance. Review of the Task List report dated 11/06/17 through 12/05/17, revealed a restorative ambulation program to walk daily to the nursing station and back to her room using a walker and one assist; however, there was no documentation a restorative program was completed. Review of the PT Evaluation and Plan of Treatment dated 12/04/17, revealed Resident #5 was evaluated by therapy due to a decline in functional status specifically ambulation. The evaluation indicated the resident was previously able to walk 150 feet with a wheeled walker and stand-by assist. Review of the record revealed no evidence of a comprehensive assessment for a nursing restorative ambulation program for Resident #5. Review of the care plan: ADL self-care performance deficit revised 05/11/17, revealed interventions including a nursing restorative program to ambulate Resident #5 daily with a walker to the nursing station and back with one assist. There were no goals identified for the restorative program. On 12/04/17 at 1:54 P.M., observation revealed Resident #5 walking with a front wheeled-walker with PT #122. The resident walked from her room to the vending/television area across from the nursing station on the 300 hall. Resident #5 was unable to walk back to room due to fatigue and weakness and staff used a wheelchair to take her back to her room. At the time of the observation, interview with STNA #11 stated the resident walked about 50 fee (TRUNCATED)

Based on record reviews and interviews, the facility failed to comprehensively assess and implement individualized interventions to restore bladder function. Actual Harm occurred when the facility failed to administer physician ordered medication to Resident #259 to treat an overactive bladder and her urinary incontinence declined to frequently incontinet. Actual Harm occurred when the facility failed to implement interventions to restore bladder function for Resident #5 and urinary continence declined from always continent to incontinent. Actual harm occurred when Resident #48 who was identified on quarterly assessment to be frequently continent of bladder experienced a decline and became always incontinent of bladder without appropriate assessments/reassessments to determine the cause of the decline and the type of incontinence. The facility failed to implement any training programs or interventions to attempt to prevent further declines and/or improve his bladder function. Actual harm occurred when Resident #55 who was occasionally incontinent of bladder declined to frequently incontinet of bladder without assessment of the type of incontinence or interventions to prevent the decline. This affected four residents (Resident #5, #48, #55 and #259) of five residents reviewed for urinary incontinence. The facility identified 15 residents occasionally or frequently incontinent of urine. Findings included: 1. Medical record review revealed Resident #259 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission physician orders [REDACTED]. Review of the bladder Admit/Readmit Screener assessment dated [DATE], revealed the resident was incontinent once or more per shift. However, the two day Bladder Diary assessment dated [DATE] and 11/22/17, revealed no evidence the resident was incontinent of urine. Review of the Medication Administration Record [REDACTED]. Review of the admission Minimum Data Set 3.0 assessment ((MDS) dated [DATE], and the 14-day MDS dated [DATE], revealed Resident #259 was moderately impaired for daily decision-making, required extensive assistance of two staff with toilet use, was not on a toileting program and was frequently incontinent of urine. Review of the MAR indicated [REDACTED]. Review of the care plan titled Bladder Incontinence dated 12/03/17, revealed the resident had urge/overflow incontinence with urgency at times and needed assistance with toileting. Review of the care plan revealed no evidence the resident was ordered medication to treat his overactive bladder. Review of the general nurse note, dated 12/04/17 revealed Resident #259 was incontinent of bladder. On 12/05/17 at 11:34 A.M., interview with Resident #259's family member stated the resident was continent of urine upon admission but had been wearing depends (incontinence product) since admission. The family member stated the resident was not receiving all of his medications and was now incontinent of urine. On 12/12/17 at 10:23 A.M., interview with the Director of Nursing verified Resident #259 was continent of urine upon admission, the resident was not administered seven doses of [MEDICATION NAME] between 11/22/17 and 12/02/17 as ordered which contributed to the resident's incontinence and the resident was not started on any type of toileting program to try to restore continence. 2. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS 3.0 assessment dated [DATE], revealed the resident required extensive assist of two staff with toilet use and transfers and was always continent of urine. Review of the quarterly MDS 3.0 assessment dated [DATE], revealed the resident was cognitively intact for daily decision-making, required extensive assistance of two for toilet use and was occasionally incontinent of urine with no toileting program. Review of the care plan titled Occasional Bladder Incontinence initiated 10/17/17, revealed no type or cause for the resident's urinary incontinence identified. Interventions included promoting fluids during the day to promote prompted voiding response, and to monitor and document possible causes of incontinence. Review of Resident #5's record revealed no evidence of a comprehensive bladder assessment or bladder diary. Review of the monthly physician orders [REDACTED]. Review of the Urinary Continence: Toileting Task dated 10/31/17 through 11/28/17, revealed Resident #5 was incontinent of urine once on 11/13/17 and twice on 11/16/17. Review of the Bedside Kardex Report dated 11/29/17, revealed Resident #5 was incontinent of bladder/bowel and check as required for incontinence. The resident's call light was to be answered timely. On 11/29/17 at 2:43 P.M., interview with Resident #5's family member revealed the resident was incontinent of urine at times because staff took too long to answer her call light. Further interview revealed the resident became embarrassed because she had accidents and wets herself but she would not be incontinent if staff answered her call light timely and took her to the bathroom. On 11/29/17 at 3:05 P.M., interview with Registered Nurse (RN) #5 verified Resident #5 was not comprehensively assessed to see if the resident's continence could be restored with a bladder retraining program. RN #5 verified Resident #5 had the ability to be continent of urine and the facility had not implemented any new interventions to restore her bladder function. 3. Record review revealed Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #48's annual assessment dated [DATE], indicated Resident #48 was cognitively intact and alert and oriented. There was no evidence of any type bladder assessment or three-day bladder tracking being completed. The resident's care plan for bladder indicated to identify voiding patterns and establish a toileting program. Resident #48 was noted to be an extensive assistance of two people with toileting and one person assist for personal hygiene. Review of Resident #48's MDS 3.0 assessments and bladder documentation indicated the following: On 11/13/17, Resident #48 was noted not to have any evidence of rejection of care, was frequently incontinent of bladder, did not need a toileting program, and required extensive assistance of two staff with toileting. Review of Resident #48 bladder documentation dated 11/13/17 to 12/13/17, indicated Resident #48 was always incontinent of bladder. There was no evidence the facility completed a comprehensive bladder and bowel assessment to attempt to determine the cause of Resident #48's incontinence and the type of incontinence. There were no interventions attempted to prevent further decline and/or improve his bladder and bowel function when these declines were identified. Review of skin alteration records dated 09/05/17 to 11/28/17, revealed the resident had moisture associated skin damage to his buttocks. On 11/28/17 the area was red and had open areas, serosanguineous drainage, and the surrounding skin was red. On 12/04/17 at 9:38 A.M., interview with Resident #48 revealed he could feel the urge to urinate, however he just goes in his brief because staff don't toilet him or even get him out of bed. The resident reported he was now always incontinent of urine and currently had pain and open areas on his buttocks. On 12/12/17 at 7:46 A.M., interview with Registered Nurse (RN) #5 confirmed Resident #48 had a decline in bladder function without evidence of a toileting program or an individualized toileting program. RN #8 was not aware of any bladder and bowel assessments completed to determine the type of incontinence or voiding pattern Resident #48 experienced. She confirmed the residents had moisture associated skin damage to his buttocks. On 12/12/17 at 9:15 A.M., interview with the Director of Nursing (DON) confirmed the facility does not have any type of formal restorative programs for bladder incontinence. 4. Review of Resident #55's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS 3.0 assessment, dated 11/18/17, revealed the resident was cognitively intact and required extensive assistance of two staff members with bed mobility, transfers, locomotion, dressing and toilet use. The resident required extensive assistance of one staff member with personal hygiene and was occasionally incontinent of bladder and always continent of bowel. Review of the bladder assessment completed 11/11/17, did not identify the type of urinary incontinence the resident experienced. The medical record did not contain documentation of a bladder diary to determine if the resident had a set pattern of incontinence. On 12/13/17 at 10:05 A.M., interview with STNA #61 revealed the resident was experiencing increased episodes of incontinence and was aware of the need to use the bathroom. Further interview revealed the resident was not on a toileting program and the staff did provide a check and change program. On 12/13/17 at 11:36 A.M., interview with RN #5 revealed the resident was within the assessment timeframe for the next MDS 3.0 assessment and the bowel and bladder section was completed. RN #5 shared the resident had a decline in urinary incontinence going from occasionally incontinent to frequently incontinent. RN #5 shared the resident's decline in urinary status was identified on 12/10/17. Further interview verified the bladder assessment did not indicate the type of urinary incontinence the resident experienced or an assessment to determine an incontinence pattern. RN #5 stated the resident was a candidate for a toileting program to restore bladder function but a program had not yet been implemented.

Based on observations, medical record review, policy review and interview the facility failed to implement a comprehensive and individualized restorative ambulation program to maintain or improve Resident #5's ambulation ability following the resident's discharge from therapy. Actual Harm occurred when Resident #5, who was discharged from physical therapy on 09/13/17, with the ability to walk between 125 and 150 feet with caregiver assistance declined and was only able to walk 50 feet with caregiver assistance. The facility failed to provide evidence a comprehensive and individualized restorative nursing program was developed and implemented and the resident had an avoidable decline in ambulation. This affected one resident (Resident #5) of one resident reviewed for restorative/rehabilitation. The facility census was 59. Findings include: Record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed the resident was cognitively intact for daily decision-making, required extensive assist with walking and had received both occupational and physical therapy. Review of the care plan titled Activities of Daily Living (ADL) self-care performance deficit, revised 05/11/17, revealed interventions including a nursing restorative program to ambulate Resident #5 daily with a walker to the nursing station and back with one assist. There was no evidence the distance to the nursing station and back was identified and there were no goals identified for the restorative program in the plan of care. Review of the Physical Therapy (PT) Discharge Summary dated 09/13/17, revealed at the time of discharge, the resident was able to walk 125 feet with caregiver assist. Therapy was discontinued due to the resident's insurance approved therapy sessions being exhausted. The prognosis to maintain the resident's current level of functioning at the time of discharge was considered good with consistent staff follow-through. Discharge recommendations included to encourage ambulation to/from the bathroom with nursing assistance. Review of the electronic task list report dated 11/06/17 through 12/05/17, revealed a restorative ambulation program to walk daily to the nursing station and back to her room using a walker and one assist. However, there was no evidence a formal comprehensive restorative assessment was completed following the resident's discharge from therapy or written evidence this ambulation program was being provided to the resident. Review of the PT Evaluation and plan of treatment, dated 12/04/17, revealed Resident #5 was evaluated by therapy due to a decline in functional status specifically ambulation. The evaluation indicated the resident was previously able to walk 150 feet with a wheeled walker and stand-by assist. On 12/04/17 at 1:54 P.M., Resident #5 was observed walking with a front wheeled-walker with Physical Therapist (PT) #122. The resident walked from her room to the vending/television area across from the nursing station on the 300 hall. Resident #5 was unable to walk back to room due to fatigue and weakness and staff used a wheelchair to take her back to her room. At the time of the observation, interview with State tested Nurse Aide (STNA) #11 revealed the resident walked about 50 feet. On 12/05/17 at 12:17 P.M., interview with Resident #5's family member revealed the resident was supposed to be on a daily walking program to the nurses' station and back but because the facility did not have enough staff, the resident only was walked to and from the bathroom. On 12/05/17 at 5:21 P.M., interview with the Director of Nursing (DON) verified Resident #5 was recently started on therapy to restore the resident's previous level of functioning in ambulation due to an identified decline. On 12/06/17 at 5:30 P.M., interview with Director of Clinical Services verified there was no evidence of a restorative assessment for the resident. On 12/06/17 at 5:45 P.M., interview with Registered Nurse (RN) #5 revealed the DON was responsible for the development and monitoring of the restorative programs. RN #5 stated if a resident had a decline, the STNA staff would tell her and she would inform the interdisciplinary team during their daily meeting. RN #5 stated currently there was no communication form to notify therapy of a resident's decline except verbally. On 12/08/17 at 10:20 A.M., interview with PT #122 revealed Resident #5 was currently receiving in-house therapy services to regain strength, balance and improve ambulation. PT #122 stated the resident's daughter, as well as staff, had noted a decline in the resident's ability to walk. This was the third time since admission the resident had received physical therapy to regain strength, balance and improve ambulation. PT #122 stated he believed Resident #5 would benefit from a restorative ambulation program to maintain her previous level of function. At 10:30 A.M., PT #122 stated it was a possible staffing concern as to why the facility did not have a restorative program and a possible reason why Resident #5 had experienced three separate declines in ambulation. PT #122 stated he knew Resident #5 was being walked initially but then gradually she was not except to/from the bathroom. On 12/08/17 at 11:00 A.M., interview with the PT #123 revealed the facility provided in-house therapy services. PT #123 stated the department typically carried about 20 residents on case load and following a resident's discharge from therapy; recommendations were typically made which might include the recommendation for a restorative nursing program. PT #123 stated under the previous ownership, recommendations for restorative nursing programs were communicated in writing to nursing staff but the new company had not approved a communication form and staff were dependent on verbal communication with nursing to implement programs. PT #123 indicated there likely were some residents who had fallen through the cracks related to the current process in place. On 12/08/17 at 1:36 P.M., interview with the DON revealed it would be her responsibility to oversee and implement a restorative nursing program in the facility. The DON revealed there was no formal restorative nursing program in place at this time and in the two years she had worked in the facility, there had never been a dedicated restorative staff, but rather floor staff/direct care staff would be responsible for providing the programming. The DON verified that although there were residents who had been discharged from therapy services with recommendations for restorative, the DON could not provide a list of who these residents were or what program they were on. Further interview revealed that due to the current staffing crisis, the facility would not be able to provide restorative nursing services to the current residents of the facility. On 12/12/17 at 2:50 P.M., the distance from Resident #5's room to the nursing station was measured with STNA #59. The distance was noted to be 32 feet. Review of the undated policy titled, Restorative Nursing revealed the purpose was to maintain independence, promote safety, preserve function, increase self-esteem, promote improvement in function and minimize deterioration of residents. Restorative nursing care actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning of residents. Residents who should be considered for a restorative program included residents who experienced a decline in functional status, residents who were assessed with [REDACTED].

Based on observations, record reviews and interviews, the facility failed to ensure residents who required assistance for activities of daily living received timely and necessary care to maintain adequate personal care and hygiene. This affected Resident #158, #157, #54, #15, #17, #48 and #7. Actual harm occurred to Resident #158 when State tested Nursing Assistant (STNA)#61 entered Resident #158's room, found the resident crying and upset and identified the resident had a large amount of stool that was dried to her skin. The resident's buttocks were observed to be red and starting to open. Resident #158 informed STNA #61 she had not been checked on by staff all night. This affected seven residents (Resident #158, #157, #54, #15, #17, #48 and #7) of 11 residents reviewed for activities of daily living. Findings include: 1. Record review revealed Resident #158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission assessment dated [DATE], revealed the resident was alert and oriented, did not have skin alterations to her buttocks and was continent of bowel. At the time of admission, the resident had an indwelling catheter. Review of the admission pressure ulcer risk assessment revealed the resident was at risk for pressure ulcer development. Review of a plan of care for Activities of Daily Living (ADL) care performance deficit, dated 11/27/17, revealed the resident required extensive assistance of two staff members with turning and repositioning in bed and toilet use. Review of the nursing progress note, dated 11/23/17 at 1:41 A.M., revealed the resident was continent of bowel. Review of a nursing progress note, dated 12/01/17 at 1:54 P.M., revealed Resident #158 had excoriation (beefy, red denuded skin) to the buttocks with new orders to apply a foam dressing to the buttocks daily. The medical record did not contain further documentation related to the cause of the excoriation or a physician's orders [REDACTED]. During an interview with Resident #158 on 12/05/17 at 11:54 A.M., and a follow up interview on 12/06/17 at 3:00 P.M., the resident shared she had concerns related to an incident that had recently occurred. The resident stated she was aware of when she needed to use the bathroom to move her bowels. The resident stated a few days prior she had to move her bowels and was unable to activate her call light due to the placement of the call light and the light being wrapped around her right arm. The resident stated the door to her room was closed and since she was unable to reach her call light, she started to yell out. She stated she waited and waited, however, no staff came. The resident stated because no one came, she laid in feces all night. The resident stated this caused her skin to breakdown and she was very sore. The resident said she told her husband, when he came in that morning and he immediately shared the concerns with the Administrator. Further interview revealed by the time she was discovered the following morning, she was crying and upset because she felt scared and felt no one was there to care for her. On 12/06/17, the Administrator submitted a self-reported incident, tracking number 6 related to an allegation of neglect/mistreatment/abuse involving Resident #158. The initial reporting revealed the resident alleged staff left her lay in feces all night. The effect noted to the resident indicated the resident was upset that she was not changed for her incontinent episode during the night. On 12/07/17 at 2:00 P.M., interview with STNA #7 revealed she and STNA #61 had provided catheter care and incontinence care to Resident #158 on the morning of 11/30/17. STNA #61 stated the resident was incontinent of a large amount of stool and believed it was evident based on the amount of stool present and the condition of the resident's buttocks the resident had not been changed in a while. On 12/07/17 at 2:10 P.M., interview with STNA #61 revealed she came in to work on 11/30/17 to work day shift which started at 7:00 A.M. STNA #61 stated upon her arrival to the unit, she began to check on the residents before breakfast. As she neared the resident's room, she found the door was closed. She entered the resident's room at approximately 7:15 A.M. and found the resident crying and upset. The resident had been incontinent of a large amount of stool and the stool was observed dried to her skin. STNA #61 stated the resident's buttocks were very red and the resident informed her she had not been checked all night. The STNA added, the resident's call light was a soft touch call light (a call light pad about four inches in diameter that is used for resident's who have difficulty pressing a call light button)noted to be on the resident's right side, under her right arm. The STNA stated the light had left an indentation in the resident's skin. STNA #61 shared the resident was unable to move her right arm much and needed the call light on her left side. STNA #61 stated she required help to change the resident and STNA #7 assisted her with the resident's incontinence care. STNA #61 revealed there had not been enough staff working on night shift this shift. On 12/08/17 at 11:50 A.M., interview with STNA #61 verified the resident's buttocks were red and starting to open. STNA #61 shared she reported the skin alteration to the nurse but was unable to recall the nurse working. Lastly, STNA #61 verified STNA #83 was responsible for the unit at the time of the alleged incident. On 12/07/17 at 2:20 P.M., interview with Licensed Practical Nurse (LPN) #27 revealed she was filling in for the facility wound nurse. LPN #27 stated on 12/01/17, she was assessing Resident #158's skin and observed excoriation to the bilateral buttocks. LPN #27 revealed the resident had reported to her that she had developed the skin issues due to staff leaving her lay in poop. LPN #27 stated being incontinent and not being changed would cause excoriation to the skin. LPN #27 stated she informed the Administrator of the president's statement at the time it was made to her. An additional interview on 12/08/17 at 8:45 A.M., revealed the incident occurred the day before the skin assessment was completed and she was unaware of the skin alteration until she observed the concern. Review of the staffing schedules revealed following the above identified concern, STNA #83 continued to work and provide resident care on 12/03/17. On 12/07/17 at 2:30 P.M., RN #5 was observed providing wound care to Resident #158. The resident was assessed to have a 1.8 centimeter (cm) in length by 1.0 cm width open area to the left buttock and a seven cm in length by 6.3 cm width reddened area to the left buttock. The area to the left buttock had bright red drainage. At 2:45 P.M., interview with RN #5 revealed the areas to the buttocks would be considered excoriation. On 12/08/17 at 9:30 A.M., interview with Resident #158's spouse revealed he spoke with the administrator after his wife informed him she laid in feces all night and no one checked on her or changed her soiled clothing. The resident's husband verified Resident #158 experienced skin break down due to not being provided timely incontinence care. On 12/08/17 at 2:16 P.M., interview with STNA #83 revealed she was working night shift (11:00 P.M. to 7:00 A.M.)on 11/29/17 and this was the first day she was not on orientation for the 300 and 400 unit. STNA #83 stated she received orientation on two midnight shifts for the 300 and 400 units and Resident #158 was a new resident to STNA #83. She stated she did not have access to the facility's computerized system and had asked the previous shift to document which residents required checking and changing throughout the night and Resident #158 was not marked on the list of residents who would require changing due to incontinence. STNA #83 stated she had not provided care to Resident #83 because she did not ring her call light and she did not enter the Resident's room after she changed the trash cans around 1:00 A.M. Further interview revealed she did not hear the resident yelling out through the night but this may have been because she was also on the other side of the unit providing resident care. 2. Record review revealed Resident #157 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the activity of daily living (ADL) self-care deficit plan of care dated 11/21/17, revealed the resident's deficit was related to functional [MEDICAL CONDITION], recent hospitalization , depression and anxiety. Interventions included the resident required extensive assistance of one staff member with oral care. Review of the admission MDS 3.0 assessment dated [DATE], revealed the resident was cognitively intact and required extensive assistance of one staff member with personal hygiene. No dental issues were identified. The facility was unable to provide documentation of oral care being provided to the resident. On 12/07/17 at 8:30 A.M., interview with Resident #157 revealed no one had assisted him with oral care since his admission and he would like to brush his teeth. On 12/07/17 at 8:35 A.M., an un-opened tooth brush and un-opened box of tooth paste were observed in the resident's bathroom drawer. On 12/07/17 at 8:40 A.M., interview with STNA #59 verified the resident's toothbrush and toothpaste were un-opened. On 12/07/17 at 2:00 P.M., interview with the DON verified the facility did not have evidence oral care was provided to Resident #157. 3. Medical record review revealed Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was readmitted on [DATE] after repair of a fractured femur from a fall sustained at the facility. Review of the Bedside Kardex Report: Personal Hygiene/Oral Care dated 11/10/17, revealed the resident required extensive assist of two staff for personal hygiene and oral care. Review of the Task List dated 11/02/17 through 11/29/17, revealed Resident #54 was to receive a shower/bath on Sundays and Thursdays. Review of the P(NAME) Response History: Shower/Bath revealed Resident #54 received a bed bath on 11/05/17 and refused a bath on 11/23/17. There was no documented evidence the resident had received a shower/bath on 11/02/17, 11/12/17, 11/16/17, 11/19/17 or 11/26/17. Review of the care plan: ADL Self-Care Performance Deficit revised 11/27/17, revealed Resident #54 required extensive to total assistance with ADL's and refused care at times. On 11/28/17 at 10:28 A.M., Resident #54's hair was observed to be greasy and uncombed. On 11/29/17 at 1:15 P.M., interview with Resident #54 stated she received showers but was unable to state how often or when her last shower was. On 12/04/17 at 8:43 A.M., the resident's fingernails were observed to have a brown dirt-like substance under the nails. On 11/29/17 at 12:45 P.M. and 3:21 P.M., interview with the Director of Nursing (DON) verified there was no evidence Resident #54 had received a shower or bath on the above dates. The DON stated sometimes staff was not able get all the showers done due to staffing concerns and the staff told the next shift to complete; however, they did not always tell her if they were not done. 4. A review of Resident #15's medical record revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A review of Resident #15's quarterly MDS 3.0 assessment dated [DATE], revealed the resident had moderate difficulty hearing and clear speech. He was able to make himself understood and was able to understand others. His vision was marked as being impaired without the use of any corrective lenses. A Brief Interview for Mental Status (BIMS) score of eight which indicated his cognition was moderately impaired. He was not known to have any behaviors and was not known to reject care. He required a limited assist of one for transfers and personal hygiene. He required physical help in part of the bathing activity with the assist of one. A review of Resident #15's activities of daily living (ADL) self care performance deficit care plan revealed he was at risk related to activity intolerance, confusion, fatigue, impaired balance and limited mobility. The interventions initiated as part of the care plan to address his self care deficit included providing a limited assist of one for personal hygiene. A review of Resident #15's task list report, used by the aides to identify a resident's care needs, revealed the resident was to be showered every Wednesday and Saturday on the night shift. The task list report revealed the resident desired the staff to shampoo his hair, complete his nail care and shave him. A review of Resident #15's shower sheets revealed no documented evidence of the resident receiving showers on Wednesdays and Saturdays which was his scheduled shower days. There was no documented evidence of the showers being refused when scheduled. On 12/05/17 at 8:37 A.M., observation of Resident #15 revealed he was unshaven with facial hair that was about a quarter inch long. It was untrimmed, scruffy and involved his neck area. Further observation on 12/05/17 at 4:54 P.M., noted him to remain unshaven but facial hair noted to be more in a goatee style than previously noted but continued to have long hairs along his jaw line. On 12/05/17 at 5:35 P.M., an interview with LPN #36 revealed Resident #15 required some assistance with his ADL's. She stated the resident would tell them when he wanted to be shaved. She thought it was his preference to be clean shaven but had known him to have a beard at times. She denied she had known him to refuse personal care to include shaving. On 12/05/17 at 6:06 P.M., an interview with STNA #100 revealed he had been employed at the facility for about nine months. He was familiar with Resident #15 but stated he had not worked much on the resident's hall in the past month. He reported the resident required supervision with his ADL care and was basically a set up help. He did confirm they had to shave the resident and it was the resident's preference to be clean shaven. He reported the resident had been known to refuse care at times. His cooperation with his ADL care and allowing them to shave him depended on the day. Residents were to be offered a shave on the days they were scheduled to receive a shower. He denied that he had offered to shave the resident since he was noted to be unshaven during observations made. He was asked to approach the resident to see if the resident wanted shaved. He was accompanied into the resident's room and was observed to ask the resident if he wanted shaved. The resident replied yes when asked if he wanted shaved and was noted to rub his chin area. On 12/05/17 at 6:20 P.M., an interview with the facility's administrator revealed Resident #15 was known to have behaviors and would refuse care at times. He indicated the resident would tell them if he wanted something done and would also tell them when he did not. On 12/06/17 at 7:30 A.M., a follow up observation of Resident #15 noted him to be clean shaven. He was sitting in the dining room eating his breakfast. On 12/06/17 at 7:40 A.M., a follow up interview with the facility's administrator revealed he was not able to locate and shower sheets for the resident to show documented evidence of his showers being given or refused when offered. He stated the aides should be completing a shower sheet when a shower was given. If the shower was offered and refused they were supposed to document that as well on the shower sheets and notify the nurse of the refusal. The nurse would then follow up with the resident to ensure the shower had been offered/ refused and the aide was just not saying that to get out of work. A review of the facility's policy on shaving residents effective on 11/30/14, revealed the residents requiring assistance would be shaved or their beard would be trimmed by self or nursing personnel to ensure personal hygiene. The facility's policy on refusal of treatment revised December 2009 revealed if a resident refused treatment, the unit manager, charge nurse or Director of Nursing would interview the resident to determine what and why the resident was refusing in an attempt to try to address the resident's concerns and explain any consequences to the refusal. They were to document the attempts to provide treatment in the resident's medical record. 5. A review of Resident #17's medical record revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A review of Resident #17's annual MDS 3.0 assessment dated [DATE], revealed the resident had clear speech and adequate hearing. She was able to make herself understood and was able to understand others. Her vision was not impaired but she had the use of corrective lenses. Her BIMS score was eight which indicated her cognition was moderately impaired. She did not have any behaviors and was not known to reject care. The resident was totally dependent on two for transfers and required an extensive assist of one for personal hygiene. For bathing, she was coded as being totally dependent and a one person physical assist. A review of Resident #17's ADL self- care performance deficit care plan revealed her deficit in ADL's was related to activity intolerance, confusion, fatigue, impaired balance, limited mobility and limited range of motion. Her interventions included providing an extensive assist of one for personal hygiene. A review of Resident #17's Plan of Care Response History for a 30 day period revealed documentation of showers provided between 11/13/17 through 12/04/17. The report indicated the resident was scheduled to receive showers on Mondays and Thursdays during the evening shift. During that time, the resident was only documented as having had one shower provided on 11/13/17. She was documented as refusing showers twice on 11/16/17 and 12/04/17. There was no other documentation showing evidence of showers being provided as scheduled. A review of Resident #17's shower sheets that were provided for review revealed evidence of only two showers being given during the past three months. She had documented evidence of receiving a shower on 10/16/17 and 11/02/17. They documented refusals of showers twice on 09/25/17 and 10/19/17. There was no documented evidence on a shower sheet of showers being offered or refused on the other days not previously mentioned. A review of Resident #17's nurses' progress notes provided no documented evidence of the resident receiving showers as scheduled. There was only one note that indicated a shower had been refused in October 2017. On 12/04/17 at 1:37 P.M., an observation of Resident #17 noted her to be sitting in her room in her wheelchair. She was noted to have long, grayish black whiskers on her chin and above her upper lip. Follow up observations of the resident on 12/05/17 at 5:04 P.M., and on 12/06/17 at 10:57 A.M., noted her to continue to have long whiskers on her chin and above her upper lip. On 12/06/17 at 11:01 A.M., an interview STNA #51 revealed she had only been employed at the facility for a month now since the new company took over. She stated she worked there before when they were under a different name. She was familiar with Resident #17 as she had cared for her during her most recent employment and also when she previously worked her. She reported the resident was an extensive assist of one for her ADL's which included personal hygiene. She stated she did note the resident had some facial hair that had not been removed but did not offer to remove it for her. The removal of unwanted facial hair was usually done with showers but she stated it could be done any time. She denied the resident had ever refused to have her facial hair removed when offered. When she worked with her in the past she always wanted it removed. 6. Record Review revealed Resident #48 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was noted to be an extensive assist of one staff with personal hygiene. On 12/04/17 at 9:33 A.M., observation and interview with Resident #48 with Licensed Practical Nurse (LPN) #101 revealed the resident finger nails were long and had a brown substance under them. The resident reported staff told him they were unable to find finger nail clippers in the past. LPN #101 verified findings and directed staff to provide the resident with nail care 7. Record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was noted to be totally dependent on staff for personal hygiene. On 12/05/17 11:49 A.M., observation and interview with Resident #7 with Activates Director (AD) #126 verified the resident's finger nails were long and had a brown substance under them. The resident indicted his nails were too long and needed cleaned and trimmed. AD #126 cleaned and trimmed the resident's nails immediately. Review of the task report revealed the resident prefers a bed bath and wants staff to wash his hair, complete nail care, and shave him.

Based on observations, record reviews and interviews, the facility failed to timely identify, implement necessary treatment and/or ensure interventions were in place to prevent the development of and ensure proper treatment of [REDACTED].#54, #48 and #55. Actual Harm occurred to resident #54 when the facility failed to ensure Resident #54 received adequate care, interventions and treatment to promote the healing of both community-acquired and facility-acquired pressure ulcers resulting in the deterioration of the pressure ulcers. Resident #54's pressure ulcers deteriorated to unstageable ulcers with gangrene and current options being discussed with the outside wound clinic included a possible amputation. This affected three residents (Resident #54, #48 and #55) of three residents reviewed for pressure ulcer development and treatment. Finding include: 1. Medical record review revealed Resident #54 was admitted on [DATE] with [DIAGNOSES REDACTED].#54 was readmitted to the facility on [DATE] after a hospitalization due to a right trochanter (hip) fracture. Review of the significant change Minimum Data Set 3.0 (MDS) assessment dated [DATE], revealed Resident #54 was cognitively intact for daily decision-making, required extensive assistance of two staff with bed mobility and toileting, and was dependent on staff for transfers. The resident was assessed to have two unstageable pressure ulcers. The resident did not have any venous or arterial ulcers. Review of the admission Skin Integrity assessment form dated 11/10/17, that was noted to be completed on 11/27/17 revealed Resident #54 had a Stage II (partial thickness tissue loss) right posterior calf (RPC) blister measuring 5.0 centimeters (cm) in length (l) by 3.0 cm in width (w) and a suspected deep tissue injury (SDTI) blister to the right heel (RH) measuring 5.0 cm in (l) by 2.0 cm in (w) with a blackened area surrounding the blister. Review of the Bedside Kardex dated 11/10/17, revealed the resident received a nutritional treat, was to be turned every two hours, pressure relieving devices when in bed and in the chair and suspend heels as tolerated. Review of the Progress Notes and record revealed the following: On 11/10/17 at 10:20 P.M., Resident #54 returned to the facility and her skin was warm, dry and fleshtone with [MEDICAL CONDITION] to the right foot and ankle. There was no evidence of a blister to the right posterior calf (RPC) or right heel (RH) documented, and on 11/11/17 an order to apply a dry dressing was written. On 11/11/17, treatments were ordered to cleanse and apply dry dressing to the RPC and RH. There was no assessment of the resident's RPC or RH documented. On 11/12/17, the resident was sent to the emergency room and returned the same day; however, there was no evidence a skin assessment was completed upon the resident's return. On 11/14/17, a late entry note revealed on 11/10/17, the resident was admitted with a fluid filled blister to the RPC and RH. Treatments were obtained and pressure relieving interventions included an air mattress, float heels, turn and reposition every two hours, and nutritional supplements. Comments included the resident was not always cooperative with position changes and wound care. On 11/15/17, the resident was eating approximately zero-to-50% of her meals and the dietitian ordered nutritional supplements including Juven and a magic cup twice a day to support wound healing. Review of the November 2017 Medication Administration Record [REDACTED]. The entries were either circled as not given or left blank with no documented explanation except on 11/18/17 when the resident refused the supplement. Review of the Food Invoice revealed Juven powder was delivered to the facility on [DATE]. On 11/16/17, a new facility-acquired reddened area on the right outer ankle was discovered. Between 11/17/17 and 11/20/17, the resident had been resistive to care and refusing medication at times while being treated for [REDACTED]. On 11/22/17, the RPC pressure ulcer increased in size and measured 9.5 cm in (l) by 7.0 cm in (w) and 0.1 cm in depth (d) and was covered with non-viable tissue. The RH also increased in size to 5.8 cm in (l) by 2.2 cm in (w) by 0.1 cm in (d). On 11/28/17, a late entry revealed the RPC had decreased in (l) but increased in (w) measuring 8.3 cm in (l) by 7.3 cm in (w). The RH had also increased in (w) and measured 5.0 cm in (l) by 3.9 cm in (w). Comments revealed the resident had been somewhat more compliant with wearing heel protectors, position changes, off loading and wound care. No new pressure relief interventions were documented as implemented. Review of the record revealed no evidence a comprehensive pressure ulcer assessment was completed between 11/28/17 and 12/09/17. On 12/09/17, a draft note was written but not finalized as completed. Review of the care plan titled Potential for Pressure Ulcer Development dated 11/28/17, revealed interventions included to assess, record and monitor wound healing and document measurements when possible; report declines or improvements to the physician; monitor dressings to ensure they remain intact and if not, report to the nurse; if treatments were refused staff was to try alternative methods to gain compliance and provide pressure relieving devices. Review of the care plan titled Actual Impairment to Skin Integrity revised 11/28/17, revealed the resident had a SDTI to the right heel and open wounds to the right posterior calf. Interventions included to document weekly treatments. On 12/11/17, the RPC increased in size to measure 13.0 cm in (l) by 5.0 cm in (w) with a foul odor noted and non-viable tissue covering the wound. The RH also increased in size to measure 7.0 cm in (l) by 4.0 cm in (w). On 12/04/17 at 9:19 A.M. and 12:45 P.M., the resident was observed lying in bed with the bed sheet on the floor. Her right foot and calf had a gauze dressing loosely wrapped and no pillow was observed at the foot of the bed or on the floor. The resident's heels were pressed against the air mattress and no pressure relieving boots were observed in the room. On 12/07/17 between 1:49 P.M. and 2:23 P.M., observation revealed Licensed Practical Nurse (LPN) #27 gathered supplies to complete the resident's pressure ulcer dressing changes. LPN #27 stated it was hard to see the posterior wound without raising the lower leg because no other staff were in the room to assist with positioning. LPN #27 proceeded to remove the soiled dressing from the resident's calf revealing a 100% necrotic (non-viable tissue) ulcer with a scant amount of bloody drainage and foul odor. LPN #27 did not change her gloves after removing the soiled dressing, proceeded to cleanse the upper portion of the wound and then placed the resident's leg back on the bed sheet without a barrier. The bed sheet was observed to have dried white/pink drainage stains and brown debris and the lower half of the RPC ulcer was not cleansed. LPN #27 applied Santyl (an enzymatic debrider) onto a sterile Q-tip, lifted the resident's leg, applied the Santyl and lowered the resident's leg back onto the resident's soiled bed sheet. LPN #27 proceeded to complete the right heel pressure ulcer treatment in the same manner. The wounds were covered with dry dressings and the lower leg wrapped with Kerlix (gauze), taped and initialed. On 12/07/17 at 2:23 P.M., interview with LPN #27 verified the above observations. On 12/11/17 at 11:15 A.M., observation revealed the resident was sitting reclined in a geri-chair with no pressure relief under the resident's right lower extremity (RLE) or heel. The RLE Kerlix (gauze) dressing was loose, and the bottom aspect of her heel/foot dressing (dated 12/10/17) had shifted towards the residents toes and was not providing any pressure relief. The resident's heel was making an indention in the vinyl covering of the foot rest and the skin of the right heel could be seen through the threads of the gauze. Resident #54 stated no one had tried to put the boots on her but she would wear them. At 11:20 A.M., the resident's dressing still remained loose with no pressure relieving boots observed, and the resident complained of pain. The surveyor informed Registered Nurse (RN) #20 of the above observation. On 12/11/17 at 11:26 A.M., RN #20 verified the above observation and verified the resident had multiple unstageable pressure ulcers to the RLE and there were no pressure relief interventions in place. The pressure relieving boots were observed in a straight back chair behind the resident's geri-chair and when RN #20 asked the resident if she could apply the boots, the resident was compliant. On 12/12/17 at 10:24 A.M., interview with the Director of Nursing (DON) verified there was no evidence of weekly skin assessments or physician notification of the decline in the resident's pressure ulcers between 11/28/17 and 12/11/17. On 12/12/17 at 11:03 A.M., interview with the DON verified the resident did not receive Juven as ordered in November 2017 because the facility had run out and it wasn't available to be given. The DON also verified the resident's pressure ulcer and skin risk care plans were not implemented as written and treatments were not consistently documented as being completed. On 12/12/17 between 4:43 P.M. and 5:23 P.M., interview with the Medical Director (MD) revealed the resident had fallen, fractured her hip and had the hip surgically repaired. When the resident returned to the facility, she had reddened areas to her right lower extremity but no blisters. The MD stated the resident does have a [DIAGNOSES REDACTED].#54's RPC and RH were caused by pressure. The resident's ability to heal was complicated due to her vascular disease and he did not want any pressure against her skin because that would contribute to the decline of the pressure ulcers. The MD stated it was his expectation to off-load any pressure and to be turned every two hours and if this was not done, it could have caused the decline in the resident's wounds. The MD indicated it was his expectation that all pressure ulcers and wounds were to be assessed daily for declines, he was to be timely notified of changes and nutritional supplements were to be administered to promote wound healing. The MD verified the resident's pressure ulcer's were unstageable, he had not been notified the wound developed a foul odor and stated the resident was recently assessed at the wound clinic to have gangrene and options, including possible amputation, were being discussed. On 12/13/17 at 10:17 A.M., interview with Registered Dietitian #124 verified it was her expectation that nutritional supplements were to be provided to promote wound healing and she had been informed that the facility had run out of Juven but did not know for how long or when it was delivered. 2. Record review revealed Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no evidence the resident had a pressure ulcers on the treatment administration records or the skin alteration sheets. Resident #48 was noted to be an extensive assist of two person for bed mobility. On 12/05/17 and 12/06/17, observation and interview with Resident #48 revealed staff do not turn him or check on him every two hours. The resident was noted during observation to be on his back and occasionally his left arm/hand would be elevated on a pillow. Review of a Certified Nurse Practitioner (CNP) note dated 12/10/17, indicated the resident had Stage I (intact non-blanchable areas of redness) pressure ulcer secondary to immobility of the patient. There was no evidence of the location of the pressure ulcer. Review of skin impairment care plan revealed the resident was non-complaint with turning and at risk for skin breakdown. Staff would observe skin conditions with daily care and report abnormalities. Other intervention included to float heels, pressure redistributing mattress, and use pillow and devices for positioning. Review of the resident electronic medical record revealed the resident's skin risk assessment (Braden score) on 08/15/17, reflected the resident was at moderate risk for pressure ulcer development. On 12/06/17 at 2:00 P.M., interview with State tested nursing assistant (STNA) #58 revealed the resident was not on a toileting or turning program. The STNA reported she had not turned or toileted the resident during her shift (7:00 A.M. to 3:00 P.M.). On 12/12/17 at 10:44 A.M., interview with Director of Clinical Services verified the CNP had identified a Stage I pressure ulcer on Resident #48, however there was no evidence the facility had assessed the area, implemented a new treatment or implemented individualized pressure relieving interventions. 3. Record review revealed Resident #55 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the Admission MDS 3.0 assessment dated [DATE], revealed the resident was cognitively intact and required extensive assistance of two staff members with bed mobility, transfers, locomotion, dressing and toilet use. The resident also required extensive assistance of one staff member with personal hygiene. The resident had two unstageable pressure ulcers (slough or eschar obscures the extent of tissue injury) on admission. Review of the pressure ulcer risk assessment dated [DATE], identified the resident at risk for pressure ulcer development. Review of the pressure ulcer skin assessment dated [DATE], revealed the resident was admitted to the facility with an unstageable pressure ulcer to the left elbow measuring two centimeters by two centimeters. The entire wound bed was covered by yellow-brown hard slough with a moderate amount of serous tan colored drainage. Current interventions to include turn and reposition every two hours, float heels and nutritional supplements as ordered. Review of the actual impairment to skin integrity related to pressure ulcers plan of care initiated 11/13/17, with interventions including the resident needs pressure relieving/reducing pad to protect the skin while up in the chair. On 12/05/17 at 9:22 A.M. and 6:00 P.M., and 12/06/17 at 11:45 A.M. and 2:00 P.M., Resident #55 was observed seated in his wheel chair with his left elbow resting directly on the armrest of the wheel chair. No pressure relieving intervention was noted to be in place. On 12/06/17 at 11:45 A.M., interview with Resident #55 verified his elbow was resting directly on the wheelchair arm rest and no pressure relieving intervention had been in place since his admission. On 12/06/17 at 4:50 P.M., interview with the Director of Nursing verified the resident did not have a pressure relieving device under his elbow when up in the wheelchair and the resident should have pressure relief to the area due to the presence of a pressure ulcer. Review of the pressure ulcer and skin care management policy revised 12/01/15 revealed prevention and treatment orders are implemented and documented as ordered. Institute appropriate, safe and effective treatment including preventative measures pertaining to the resident wound care needs, both immediate and long term.

Based on observation, record review and interview the facility failed to develop and implement an effective pain management program for Resident #54. Actual Harm occurred when staff failed to provide adequate pain relief, including the administration of as needed pain medication prior to providing personal care and wound care resulting in the resident crying out in pain, experiencing verbal and non-verbal signs of increased pain while staff provided care. This affected one resident (Resident #54) of three residents reviewed for pressure ulcers. Findings include: Medical record review revealed Resident #54 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#54 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #54 was cognitively intact for daily decision-making, required extensive assistance of two with bed mobility and toileting, and was dependent on staff for transfers. The resident had two unstageable pressure ulcers and received scheduled, as needed (PRN) and non-medication interventions for complaints of frequent pain. The resident had no venous or arterial ulcers. Review of the pain assessment dated [DATE], revealed the resident had right hip pain and exhibited non-verbal signs of pain indicating hurts a whole lot using a face scale. The pain assessment revealed the resident's pain had an effect on the resident's activities of daily living including sleep and rest, social activities, appetite, physical activity and mobility Methods to alleviate the resident's pain included pain medication, repositioning for comfort and elevation. The resident's goal was to have no pain. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed pain made it hard for the resident to sleep and limited her day to day activities, because of pain. Review of the physician orders [REDACTED]. Review of the December 2017 physician orders [REDACTED].#54. Review of the care plan titled Acute Pain revised 11/28/17, revealed the resident was at risk for pain related to a fracture right hip repair. Staff was to observe the resident for verbal and non-verbal signs of pain with movement of the right leg. The resident's pain was alleviated with pain medication, pain medication was to be given 30 minutes prior to treatments or care, and the need for pain relief was to be anticipated and immediately respond to complaints of pain. Review of the care plan titled Potential for Pressure Ulcer Development dated 11/28/17, revealed interventions including to treat pain as ordered prior to treatments, turning etc. to ensure the resident's comfort. Review of the Medication Administration Record [REDACTED]. The resident also received 650 mg of Tylenol on 12/13/17 for pain. There was no evidence the resident was medicated prior to treatments or care. On 12/07/17 between 1:32 P.M. and 2:23 P.M., observation of Resident #54 including a mechanical lift (Hoyer) transfer, incontinence care and pressure ulcer dressing changes revealed the following: Licensed Practical Nurse (LPN) #27 and State tested Nursing Assistant (STNA) #11 were preparing to transfer the resident to bed using a Hoyer lift. The resident was reclined in a geri-chair with no signs of pain. Upon placing the lift pad loops on the hooks of the Hoyer lift, the resident was calling out oh, oh, oh God. Staff continued with the transfer despite the resident calling out in pain and reaching towards her hip. Once the resident was lowered to the bed, the resident was observed pursed lip breathing. LPN #27 and STNA #11 told the resident they had to get her back to bed to do incontinence care and complete the dressing change. LPN #27 was positioned next to the bed on the right side of the resident and STNA #11 on the left. STNA #11 placed her hands on the resident's right hip and upper back, and pulled the resident towards her while LPN #27 pushed from behind. The resident began screaming out loudly stating don't you dare, don't you dare, don't you dare. LPN #27 told the resident she was wet and needed changed. The resident continued to cry out. After incontinence care, STNA #11 left the room and LPN #27 allowed the resident to rest in bed for nine minutes without movement while she was preparing for the dressing change. Prior to starting the dressing change, LPN #27 asked the resident if she was having any pain and she said no. The bed was in the low position, LPN #27 knelt down and raised the resident's right leg up to observe the posterior right calf and right heel pressure ulcer. LPN #27 stated it was hard to see the posterior wound without raising the lower leg higher because there were no other staff was in the room to assist with positioning. The resident was moaning and crying out stop, please stop during the dressing changes which lasted 14 minutes. When the nurse was finished with the resident's care she told the resident you did good. At no time did LPN #27 stop the transfer, incontinence care or dressing change to provide the resident with pain relieving measures. Interview with LPN #27 verified the above observations and stated she should have medicated the resident prior to providing care to the resident. Review of the undated policy titled Pain revealed staff was to identify pain and develop interventions consistent with the resident's goals and needs that address the underlying causes of pain. Pain management was alleviating the resident's pain to a level that was acceptable to the resident and based on their clinical condition and established treatment goals. Pain assessments were to be completed upon admission, readmission and as needed. The resident's pain was to be assessed with [REDACTED]. Effectiveness was to be reassessed after administration.

Based on observation, medical record review, policy review and interview the facility failed to ensure medications were administered as ordered resulting in significant medication errors with potential adverse effects, delay in treatment and hospitalization s. Actual Harm occurred to Resident #1 when the facility failed to notify the physician of a urine culture timely, the resident was administered two doses of a resistive antibiotic prior to ordering an antibiotic that was sensitive to the organism. The resident became symptomatic including confusion and visual hallucinations and was admitted to the hospital for a complicated urinary tract infection [MEDICAL CONDITION] with failed outpatient treatment. Actual Harm occurred to Resident #54 when the facility failed to administer antibiotics as ordered for a diagnosed UTI on three separate occasions between 11/03/17 and 11/16/17, resulting in a hospitalization on [DATE], and an evaluation for combativeness on 11/16/17. This affected two of four residents reviewed for urinary tract infections. In addition the facility failed to administer medications as ordered for Resident #259, #18 and #45. This affected three of four residents reviewed for medication administration. Findings include: 1. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the telephone physician orders [REDACTED]. Review of the Urine Culture results dated 11/06/17, revealed 50,000-100,000 escherichia coli ESBL (chemicals which are produced by a certain type of bacteria that breaks down antibiotics, thereby making infections very hard to treat). The organism was resistive to Bactrim but sensitive to [MEDICATION NAME]. Review of two different handwritten orders on page 1 and page 2 of the culture result revealed an order to administer Bactrim DS twice a day for seven days and another order to discontinue Bactrim DS and start [MEDICATION NAME] ([MEDICATION NAME]) 100 mg twice a day for 10 days. There was no date, signature or title of the person who wrote the order. Review of the telephone physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. The resident was started on [MEDICATION NAME] and received a total of four doses between 11/09/17 and 11/10/17. Review of the progress notes revealed on 11/08/17, a call was placed to the physician and urinalysis results from 11/06/17 were faxed to the physician. The resident had no signs of confusion between 11/06/17 and 11/09/17. On 11/10/17, the resident began having periods of confusion, visual hallucinations and altered mental status. The resident was sent to the hospital for an evaluation and admitted to the hospital with [REDACTED]. On 11/28/17 at 1:40 P.M. and 2:00 P.M., interview with Registered Nurse (RN) #5 verified the physician was not notified of Resident #1's urine culture results until 11/08/17 and two doses of a resistive antibiotic (Bactrim DS) were administered resulting in a three day delay in treatment. RN #5 also verified the resident became symptomatic on 11/10/17 and was admitted to the hospital with [REDACTED]. 2. Medical record review revealed Resident #54 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital discharge orders dated 11/03/17, revealed to administer Bactrim DS (antibiotic) 800/160 mg twice a day for a UTI. Review of the Medication/Treatment Administration Record dated 11/03/17 through 11/07/17, revealed the resident received five of seven doses. On 11/07/17, the resident was sent to the hospital for altered mental status and admitted to the hospital with [REDACTED]. On 11/10/17, Resident #54 returned to the facility with orders to continue administration of Bactrim DS twice a day for a UTI. The antibiotic was started at the hospital on [DATE], and was to be administered for a total of 10 days. Review of the MAR indicated [REDACTED]. On 11/16/17, the resident was sent to the hospital for another evaluation due to being combative. The resident returned with orders to administer [MEDICATION NAME] (antibiotic) 500 mg daily for seven days and to continue Bactrim DS. There was no evidence Bactrim DS was transcribed or administered and the resident received three of seven doses of ordered [MEDICATION NAME]. Nurse's Medication Notes revealed the resident refused two doses; however, there was no evidence the antibiotic was continued until all doses were administered. Review of the care plan titled Urinary Tract Infection dated 11/16/17, revealed to administer antibiotics as ordered. On 11/28/17 at 11:58 A.M., interview with RN #5 verified Resident #54 was diagnosed with [REDACTED]. Review of the Documentation of Medication Administration policy revised April 2007 revealed the facility was to maintain a record to document all medications administered. 3. Medical record review revealed Resident #259 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the transfer physician orders [REDACTED]. heart rate less than 60; [MEDICATION NAME] (fast acting insulin) 5 units subcutaneous three times a day and hold the insulin if blood glucose was less 150, glucose monitoring before meals and at bedtime; daily weights and vital signs three times a day including pulse oximetry. The orders also revealed to administer aspirin (ASA) [MEDICATION NAME] coated (coating on medication that either protects drugs from the acidity of the stomach, the stomach from the detrimental effects of the drug, or to release the drug after the stomach) 81 mg daily. Review of the admission physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. The resident was also administered chewable ASA (absorbs faster than regular aspirin) versus the ordered [MEDICATION NAME] coated aspirin between 11/22/17 to 12/08/17 when the surveyor notified the facility of the error. Further review of the MAR indicated [REDACTED]. Glucose monitoring and blood pressure monitoring began on 12/03/17 and daily weights began on 12/04/17. On 12/05/17 at 11:34 A.M., interview with Resident #259's family member stated the resident was experiencing an increase in confusion and urinary incontinence about two weeks after admission. Upon review of the physician orders, the resident's family member realized the resident had not been receiving medications and monitoring that was ordered. Resident #259's family member stated the confusion was probably due to his glucose levels because the facility was not monitoring his blood glucose or administering his insulin. The facility was also giving the resident blood pressure medication without monitoring. On 12/13/17 at 11:40 A.M., interview with RN #5 verified Resident #259 did not receive medications as ordered due to omission and transcription errors. 4. Medical record review revealed Resident #18 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the physician order [REDACTED]. On 12/06/17 at 12:03 P.M., observation revealed Licensed Practical Nurse (LPN) #6 gathered new IV tubing, spiked the prefilled 50 milliliter (ml) bag of [MEDICATION NAME] and primed the tubing allowing an excessive amount of IV fluid to prime the tubing prior to administration. LPN #6 stated she had too get all the air bubbles out. Further observation of the [MEDICATION NAME] IV 50 ml bag revealed less than half of the IV solution remained. On 12/06/17 at 12:37 P.M., observation of Resident #18's IV bag revealed no solution remained and the pump display revealed a total of 32 ml of [MEDICATION NAME] had infused. On 12/06/17 at 12:39 P.M., interview with LPN #6 verified Resident #18 did not receive the ordered dosage of [MEDICATION NAME]. 5. Medical record review revealed Resident #45 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. On 12/07/17 at 8:35 A.M., observation revealed Resident #45 had a prefilled 100 ml bag of [MEDICATION NAME] 500 mg (antibiotic) IV solution infusing and the remaining dose to infuse was 99 ml. The solution bag appeared to be only half full. LPN #6 stated she primed the tubing and had just hung the [MEDICATION NAME] at the prescribed rate of 100 ml. On 12/07/17 at 9:33 A.M., observation of the IV pump revealed the [MEDICATION NAME] bag was empty and the pump display revealed a total of 88 ml of [MEDICATION NAME] had infused. At the time of the observation, Registered Nurse (RN) #5 verified only 88 ml of the IV [MEDICATION NAME] had infused. Review of the undated intravenous pump Operator's Manual -6.05/6.2.4 Revision D, revealed standard gravity IV set priming techniques were to be used to purge air from the tubing. The bolus accuracy must be programmed with either a specific rate or amount to be delivered in a certain amount of time. Accuracy was dependent on the resultant flow rate that's obtained from the calculation of the volume to be delivered in the time requested. Review of the policy: Administering Medications revised April 2013, revealed medications were to be administered in a safe and timely manner, and as prescribed. Review of the policy: Pharmacy Services-Role of the Provider Pharmacy revised August 2010, revealed the provider pharmacy agreed to provide services that comply with applicable facility policies and procedures; accepted professional standards of practice and laws and regulations including supplying the facility with medications that were needed. Routine pharmacy services were to be provided seven days a week and emergency pharmacy service 24 hours per day, seven days a week. Medications were to be delivered to the facility. Review of the Medication-Related Errors policy dated 201,7 revealed if a medication reaches a resident in error, the facility should notify pharmacy of any possible dispensing occurrence and notify physician/prescriber and obtain further instructions and/or orders. Facility staff should monitor the resident in accordance with physician instructions. Review of the Documentation of Medication Administration policy revised April 2007 revealed the facility was to maintain a record to document all medications administered. This deficiency substantiates Complaint Number OH 795.

Based on observation, record review and interview the facility failed to ensure Resident #20 received adequate assistance to turn/reposition in bed. The facility also failed to ensure fall interventions were in place as care planned for Resident #21. Actual harm occurred to Resident #20 when the facility failed to provide two staff to reposition the resident while in bed, in accordance with the plan of care resulting in a fall with bilateral hip fractures and pelvic fracture. This affected two residents (Resident #20 and #21) of three residents reviewed for accidents. Findings include: 1. Review of Resident #20's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment, dated 07/12/16 revealed the resident was cognitively impaired, incontinent of bowel and bladder and at risk for falls. The assessment revealed the resident required extensive assistance from two staff for bed mobility and transferring. The current fall care plan, initiated 10/23/15 revealed Resident #20 required extensive assist from two staff for turning and repositioning. Review of a nursing progress note, dated 08/24/16 at 4:48 A.M. revealed Licensed Practical Nurse (LPN) #59 was notified Resident #20 fell out of bed while State tested Nursing Assistant (STNA) #55 was giving her a bath and changing her sheets. A statement from the STNA revealed, I was washing her and I rolled her and she jerked and fell out of bed. The resident was assessed by LPN #59 to have bruising to the right cheek bone. Resident #20 was transported to the hospital for evaluation. A physician progress notes [REDACTED].#20 with the bed in a high position and the resident fell off the bed, landing on her left hip. Review of the facility investigation report, dated 08/24/16 revealed STNA #55 was giving a bed bath to Resident #20. During the bath, the resident was assisted to roll over by the STNA. The STNA rolled Resident #29 away from her. Resident #20 jerked and rolled off the bed onto the floor. Review of hospital records, dated 08/24/16 through 09/06/16 revealed Resident #20 was admitted to the hospital with [REDACTED]. The resident did not return to the facility following the hospitalization . On 09/13/16 at 11:35 A.M., interview via telephone with STNA #55 revealed she was caring for Resident #20 on 08/24/16 at the time of her fall. The STNA indicated she was washing the resident's back side and was the only staff member in the room. The resident was on her side and she was washing her bottom holding the resident with one hand and washing her with the other hand. The resident had a history of [REDACTED]. The STNA indicated the bed was at her waist level, she was approximately five feet two inches which revealed the bed was approximately three feet from the floor. Interview on 09/13/16 at 3:13 P.M. with the Director of Nursing (DON) verified Resident #20 sustained a fall from bed and subsequent fractures on 08/24/16 when she was being turned by one STNA. The DON verified the resident's current fall care plan and MDS assessment dated [DATE] revealed the resident required two staff for turning and repositioning. Review of policy and procedure for bed making occupied dated 12/2009 revealed the need for a second staff member when changing an occupied bed. The policy indicated to have the second staff member on the opposite side of bed, as you roll patient. 2. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident was at risk for falls. The current care plan related to falls included interventions to have a body pillow while in bed and reinforce need to call for assistance. Observation of Resident #21 on 09/12/16 at 11:08 A.M., 12:34 P.M., 2:55 P.M. and 4:44 P.M. and on 09/13/16 at 8:45 A.M., 12:00 P.M., and 2:00 P.M., revealed the resident was in bed with no body pillow in place. Interview on 09/13/16 at 3:13 P.M. with the Director of Nursing (DON) verified Resident #21 had a current plan of care which determined the need for a body pillow as a safety intervention to decrease falls. The DON verified the body pillow was not being used for Resident #21 as noted during the above observations. This deficiency substantiates Complaint Number OH 799.

Based on closed medical record review, review of the hospital transfer sheet and staff interview, the facility failed to timely assess a resident's heels when he was in traction resulting in a pressure ulcer to his left heel. This affected one (Resident #106) of three residents whose medical records were reviewed for pressure ulcers. The census was 74. Harm occurred when Resident #106 who was initially admitted to the facility on [DATE] and developed an avoidable unstageable pressure sore to his left heel. Findings include: 1. Review of Resident #106's closed medical record revealed Resident #106 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the 03/11/15 admission Minimum Data Set (MDS) assessment revealed Resident #106 was independent for daily decision making, extensive assist of two for bed mobility and had one unstageable pressure ulcer. Review of the admission Braden Scale (a means of determining if the resident was at risk for pressure ulcers) dated 03/04/15 revealed the resident was at high risk for pressure ulcers related to bedfast, slightly limited mobility, probably inadequate nutrition and a potential shear and friction. The admission assessment dated [DATE], revealed Resident #106's left heel was not assessed due to leg set up in traction. admission orders [REDACTED]. On 03/09/15, five days after admission, a physician's orders [REDACTED]. Review of the 03/04/15 transfer record from the hospital identified under the skin breakdown section, the resident had red elbows and mushy heels. Review of the 03/09/15 Pressure Ulcer Healing Chart revealed an unstageable pressure ulcer to the left heel measuring 4.0 centimeter (cm) in length (L) by 3.0 cm in width (w). A nurses' note dated 03/09/15 at 12:28 P.M., indicated resident admitted to facility with left leg in Bucks traction. Unable to assess left heel upon admission. New order received 03/09/15 to release Bucks traction to assess the left heel then replace. Upon removal of traction from the left leg a 4.0 centimeter (cm) in length (L) by 3.0 cm in width (W) soft, dark soft purple area was noted to the left heel. Skin currently intact. No odor noted. Scant amount of bleeding when cleansing the area. Surrounding skin dark pink and slow to blanch. No complaint of pain or discomfort voiced. Area has suspected deep tissue injury. On 08/13/15 at 1:24 P.M., interview with Licensed Practical Nurse (LPN) #41 indicated staff had to wait for an order from the doctor to remove the traction and assess the heel. On 08/13/15 at 1:46 P.M., interview with Physical Therapist (PT) #24 indicated that he set up the Buck's traction when Resident #106 arrived at the facility. PT #24 indicated he thought the staff assessed the skin prior to the traction being applied. He indicated that the Buck's traction was a Velcro foam pad that would extend from the knee that went all the way around the foot and was Velcro'd in place. The strap pulls were sewn into the foam pad and would pull from the top of the foot. PT #24 indicated that he did not assess the skin and did not see the heel or notice a pressure ulcer. He indicated the nurses do it. PT #24 indicated to pull Resident #106 up in bed he took the weight off, releasing the traction. PT #24 indicated he educated the staff on taking the weight off the pulley to pull the resident up in bed. PT #24 indicated staff never asked him if they could take off the Velcro pad off to assess the resident's skin. He indicated there was no reason why they could not remove it since the weight was released when he was pulled up in bed. On 08/13/15 at 2:10 P.M. interview with LPN #41 verified Resident #106's left heel was not assessed on admission nor was the physician called for five days to obtain an order to remove the pad to assess the area under the foam of the Buck's traction. LPN #41 verified upon assessment (03/09/15) the resident had an unstageable pressure ulcer to the left heel upon removal of the traction pad.

Based on record review, policy review and staff interview, the facility failed to ensure residents were provided the care and services necessary to restore as much normal bladder function as possible. This affected two #16 and #84) of three residents observed for urinary incontinence. The census was 74. Harm occurred when Residents #16 and #84 declined in their continence status with no intervention having been attempted. Findings include: 1. A review of Resident #84's medical record revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was readmitted to the facility post hospital stay on 04/22/15. A urinary incontinence assessment completed on 04/22/15 upon readmission revealed the resident's risk factors for urinary incontinence included the her [DIAGNOSES REDACTED]. She was also noted to be receiving several medications that increased her risk for urinary incontinence. The type of incontinence the resident was indicated to have was functional incontinence. The urinary incontinence assessment referred to the comment section for a summary of findings of the assessment but did not include any notes in the comment section. A review of an activity of daily living (ADL) report from 04/23/15 to 04/29/15 confirmed the resident had multiple episodes of urinary incontinence with some control present. She was marked as being continent 13 times during that assessment period and incontinent 10 times. An admission Minimum Data Set (MDS) assessment, (an assessment tool used by the facility to identify a resident's level of care) dated 04/29/15 revealed the resident did not have any communication difficulties as she was able to make herself understood and was able to understand others. Her brief interview for mental status (BIMS) score was 13 which identified her as being cognitively intact. She was not recorded as having had any behaviors and was not noted to reject any care. The MDS indicated she required an extensive assist of one for transfers and ambulation in her room. She required an extensive assist of two for toilet use. The MDS also assessed her as being incontinent of her bladder and not on a toileting program. A urinary incontinence assessment completed 07/14/15 revealed the resident continued to be assessed as having functional incontinence with similar risk factors for urinary incontinence as previously identified in the prior assessment. The comment section did include documentation of the resident being incontinent of both her bowel and bladder and stated she was in need of assistance to the bathroom. The assessment did not indicate whether or not the resident was appropriate for a toileting program. A review of the ADL report from 07/14/15 through 07/20/15 revealed the resident was always incontinent of her bladder. The report did not show any episodes where she was continent of her bladder. A quarterly MDS assessment dated [DATE] revealed Resident #84 was always incontinent of her bladder. There was no change in her communication ability compared to the admission MDS. Her BIMS score reduced from a 13 to a five. A score of five indicated the resident's cognition was severely impaired. No behaviors or rejection of care was noted. She required extensive assist of two for transfers and toilet use. She only required a limited assist of one needed for walking in her room. She was coded on the MDS as always being incontinent of her bladder. She was still not identified as being on a toileting program. A review of Resident #84's care plans revealed she was at risk for urinary incontinence which was included as part of her plan of care. The goal was for the resident to not have any complications due to her incontinence. There were only two interventions listed on the care plan which included the need to report changes in the amount, frequency, color or odor of urine and to report any changes in skin integrity found during daily care. The urinary incontinence care plan did not provide any evidence of a toileting program being used or other interventions to restore as much of the resident's bladder function as possible. A review of the facility's Incontinence Management Practice Guide, dated 03/2012, revealed ongoing management strategies included the need to re-evaluate resident's with urinary incontinence on a regular basis. The implementation of a bladder diary was deemed important during that stage. A bladder diary was an objective evaluation tool useful in identifying types of voiding dysfunction and urinary incontinence. The caregivers were to record the timing of continent and incontinence episodes and the resident's amount of fluid intake. Associated events such as urgency, pad changes and activity were also to be recorded. The bladder diary would provide a baseline of the resident's voiding pattern, provide an objective measurement of the achievement of outcomes, identify the frequency of voiding dysfunction or urinary incontinence, develop individual treatment goals and identify residents who were appropriate for behavioral management. The incontinence management practice guide indicated scheduled toileting or habit training was a type of toileting program that toileted the resident at regular intervals on a planned basis that coincided with the resident's voiding habits such as every two, three or four hours or before or after meals, upon rising and at bedtime. Residents that had a high frequency or high volume of incontinent episodes, had moderate to severe mobility and cognitive impairment and accepted toileting assistance when they were told it was time to toilet were good candidates for that type of program. An algorithm that was part of the facility's practice guide indicated if a resident had a history of [REDACTED]. They were then to develop a toileting program as appropriate. On 08/13/15 at 1:20 P.M., an interview with State-tested Nurse Aide (STNA) #85 revealed Resident #84 was both incontinent and continent of her bladder. She stated the resident was incontinent about half of the time they checked her. She reported they would usually find the resident incontinent in the mornings but on some days she would be continent the remainder of the day. Other days she would always be incontinent when they checked her. The resident would put her light on at times to request to go to the bathroom. She stated when they offered to take her or when the resident asked to be toileted they would find her already incontinent. She denied that the resident was on an individualized toileting schedule based on her voiding pattern. She stated they asked her if she wanted to go to the bathroom every two hours like they do for all the other residents or they change her every two hours if she was found to be already wet. She reported the resident wore an incontinent brief at all times. On 08/13/15 at 1:30 P.M., an interview with the Director of Nursing (DON) revealed the nurses on the floor or the unit managers were the ones who were to complete the urinary incontinence assessments. They were to be done upon admission and when there was a change in the resident's continence status. She stated they have used the bladder diaries in the past to identify a resident's individual voiding pattern. She was not certain that one had been done for the resident. She stated the urinary incontinence assessments were reviewed in their Eagle Room meeting after completed and it was determined in that meeting if a toileting program was needed. She stated those urinary incontinence assessments were reviewed in their morning meetings when a change in a resident's continence status occurred. She did not recall reviewing Resident #84's urinary incontinence assessment in their morning meeting or determine if the resident needed placed on a toileting program when she was noted to have a decline in her urinary continence status going from being frequently incontinent to always incontinent on her latest quarterly MDS assessment. She denied that the facility had any restorative nurses who evaluated the residents for the need for toileting programs. She checked to see if there was any evidence of a bladder diary being completed for the resident and reported that she was not able to find one as per their policy. She agreed a bladder diary should have been completed as part of the resident's assessment and for determining what specific times the resident could have been toileted to reduce the frequency of her urinary incontinence. She also agreed that based on the definition of a scheduled toileting or habit training program and the resident's characteristics she would have been appropriate for that kind of program. She acknowledged toileting the resident ever two hours was not an individualized toileting program since it did not focus on her own individualized voiding pattern. 2. Review of Resident #16's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of annual Minimum Data Set ((MDS) dated [DATE] revealed Resident #16 was cognitively intact. Review of the urinary incontinence assessment dated [DATE] revealed Resident #16 had dementia, [MEDICAL CONDITIONS], impaired mobility, recurrent urinary tract infections, diuretics, and there was no indication on the type of incontinence. Review of Resident #16's urinary incontinence assessment dated [DATE] revealed Resident #16 did not have dementia, risk factor included [MEDICAL CONDITIONS], diuretics, antihypertensive, and had functional incontinence. Review of Resident #16's toileting records dated 01/13/15 to 06/30/15 revealed Resident #16 was only continent of urine seven of 39 documented times. Review of Resident #16's medical record revealed no evidence that Resident #16 had three day bladder diary or bladder training. Review of Resident #16's care plan for urinary incontinence related to impaired mobility and physical limitation and provides incontinent care as needed. Review of Resident #16's admission MDS dated [DATE] revealed Resident #16 was frequently incontinent of urine and there was no evidence of toileting program. Review of Resident #16's MDS dated [DATE] revealed Resident #16 was frequently incontinent of urine and there was no evidence of toileting program. Review Resident #16's quarterly MDS dated [DATE] revealed Resident #16 was always incontinent of urine and there was no evidence of toileting program. Interview with Register Nurse (RN) #44 on 08/12/15 at 9:42 A.M. verified Resident #16 had a decline in urinary frequency from frequently incontinent to always incontinent. RN #44 affirmed Resident #16 was continent one time from 02/28/15 to 03/06/15 and was incontinent every day from 05/31/15 to 06/06/15. Interview with STNA #8 on 08/13/15 at 9:45 A.M. revealed Resident #16 was cognitively impaired and was unable to tell staff when she needed to go. Resident #16 was on every 2 hours and toilets upon rising, spends the majority of time in bed and wears pull ups 24/7. Interview with RN #60 on 08/13/15 at 11:25 A.M. revealed Resident #16 had not had a three day bladder assessment or a bladder training program. RN #60 affirmed Resident #16 was cognitively intact but was physically impaired. RN #60 affirmed it took a lot of encouragement to even get Resident #16 to get in a chair for two hours a day.

Based on record review and staff and resident interview, the facility failed to ensure a resident was properly positioned in bed for incontinence care resulting in a fall. This affected one of three residents reviewed for accidents. (Resident #21). The census was 74. Harm occurred when Resident #21 was turned in bed with assistance of one staff member instead of two and fell to the floor resulting in multiple contusions leading to hemarthrosis (bleeding into joint spaces) of bilateral knees and [DIAGNOSES REDACTED] (soft tissue infection) of the right leg resulting in four surgeries to his knees and leg. Findings include: Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with acute paralytic polio, debility, peripheral vascular disease, morbid obesity and was incontinent of feces and urine. Review of the 06/06/15 quarterly Minimum Data Set (MDS) assessment revealed Resident #21 was independent with daily decision making, extensive assist of two for bed mobility and toileting, totally dependent of two staff for transfers, had bilateral lower extremity impairment and was 63 inches tall and weighed 293 pounds. Review of the Nurses' Notes dated 06/12/15 at 9:00 A.M., revealed Resident #21 was receiving morning care and rolled out of bed to the floor. The resident was sent out to the emergency room (ER) for evaluation. A skin assessment completed upon return from theER on [DATE] at 3:15 P.M. The assessment revealed the resident had to the left side of his back had a 14 centimeter (cm) in length (L) by 0.25 cm in width (W) scratch. The left knee had a 25.0 cm L by 10.0 cm W bruise. The right foot had a 23.0 cm L by 23.0 cm W bruise. The right knee had an 18.0 cm L by 23.0 cm W bruise. The right side of his forehead had a 4.0 cm L by 1.5 cm W bruise. The right elbow had a skin tear 1.0 cm L by 0.5 cm W and 1.0 cm L by 0.7 cm W. The left hand pinky finger had a 2.0 cm L by 0.5 W bruise. The left elbow had a 3.0 cm L by 1.5 cm W abrasion. An intravenous puncture mark was observed to his left anticubital area. The Nurses' Notes dated 06/13/15 at 3:36 P.M. indicated Resident #21 has large fluid filled blister on right knee approximate size of a fifty cent piece. On 06/14/15 at 5:53 P.M. the Nurse's Notes indicated Resident #21 was complaining of pain to right leg. When the nurse gave him his pain medication at 5:00 P.M. he felt warm. Temperature was 102 degrees Fahrenheit (F), pulse 109 beats per minute (bpm), respirations 20 per minute and his oxygen saturation was 89 percent. Resident #21's Right leg is hot to touch, very edematous, especially around his knee, with dark purple & black bruising. Right knee is much worse. Blister on knee from yesterday has reabsorbed for the most part and now has a dime size blister on top on Right foot. Resident #21 was sent to the hospital. Review of the Nurses' Notes dated 06/14/15 at 9:53 P.M. the documentation indicated the staff spoke to the ER nurse and Resident #21 had been admitted to the Intensive Care Unit with [DIAGNOSES REDACTED]. Review of the Hospital Record revealed Resident #21 was admitted with a hemoglobin of 8.5 grams to deciliters (g/dl) and hemarthrosis, a bleeding into the joint spaces of the right knee. On 06/17/15, Resident #21 had bilateral knee hematomas debrided. On 06/19/15, the left knee wound was closed and the right leg tibia area and knee were debrided again. On 07/01/15, the right leg was again debrided and the resident was re-admitted to the facility on [DATE]. Review of the medical record revealed Resident #21 was again hosptalized on [DATE] for a scheduled 07/24/15 debridement of the right leg for [DIAGNOSES REDACTED], a serious bacterial infection (flesh eating disease, in the anterior calf muscles and returned to the facility on [DATE]. The wound culture obtained on 07/24/15 was positive for Proteus Mirabilis, Stapholococcus aureus and [DIAGNOSES REDACTED] Enterococcus Group E Strep and received the antibiotics Ampicillin and Bactrim DS for 10 days each. Review of the 08/11/15 skin alteration records revealed the right foot had a wound that measured 9.8 cm L by 4.2 cm W by 0.5 cm D with two areas of the tendon visible and three sutures around the edges with no drainage and purple scarring. The right calf wound measured on 08/11/15 was 28.6 cm L by 9.0 cm W by unable to determine depth with areas of exposed muscle and tendon and scant serosanguinous (composed of serum and blood) drainage with purple scarring around the edges. On 08/11/15, the left knee had a 1.0 cm L by 1.0 cm W intact scab without drainage at an old drain site. Review of the [DATE] readmission pain assessment revealed Resident #21 reported frequent pain to the right knee, lower leg, ankle and foot with dressing, bathing, positioning changes and with dressing changes. Re-admission orders [REDACTED]. The 07/29/15 readmission continued the same pain medication as the 07/10/15 admission with the addition of Norco 5/325 mg two tablets for severe pain every four hours as needed. Review of the at risk for falls plan of care initiated 04/09/07 effective thru 06/24/15 revealed an intervention to provide assist to transfer with Hoyer lift and two staff as indicated. There was not an intervention for the amount of assistance needed with care until 06/12/15. Review of the incontinence plan of care initiated 06/01/11 and current through 06/24/15 revealed no evidence of an intervention related to the amount of assistance needed in turning for care. Review of the Activity of Daily Living (ADL) self care deficit plan of care initiated 04/09/07 and current through 06/24/15 revealed an intervention dated 08/23/13 for extensive assist to dependent of one to two staff for bathing/shower, personal hygiene, dressing, toileting and bed mobility. Review of the ADL task summary initiated 11/15/11 indicated Resident #21 was ADL assist - extensive assist to dependent of 1-2 staff. For your information (FYI) resident prefers to get up in the morning around 10:00 A.M. and to go to bed around 8:30 P.M. Use large sling with Hoyer lift for transfers. Review revealed on 06/12/15, the ADL summary was changed to extensive assist to dependent of two staff for ADL, bed mobility and toileting. Review of the Kiosk (small physical structure often a computer and display screen) bed mobility State-tested Nurse Aide (STNA) documentation revealed that 06/06/15 through 06/11/15 STNA #37 was the only staff member that documented Resident #21 was a one assist for bed mobility. All the other documented entries for that period identified that staff assistance of two for bed mobility. On 06/06/15 and 06/07/15, STNA #37 also documented she provided bed mobility as a one person physical assist for Resident #21. On 08/12/2015 at 12:44 P.M. interview with Resident #21 indicated a staff member rolled him on his side to clean him up and he rolled on the floor. He stated there are supposed to be two. He indicated he was in a lot of pain from falling and he still has a lot of pain in his right leg. Review of Disciplinary Action revealed STNA #37 received an action plan dated 06/14/15 indicating that during care, Resident #21 was rolled away from STNA #37 instead of being rolled toward her. Expectations were that she should always ask for assistance or use proper technique while providing care. The solution was to roll patient towards her at all times while providing incontinence care. The action plan was to ask any available staff with two assist or roll patient toward you with one assist. Review of the staff development revealed on 06/12/15 incontinence care inservice was presented. The Incontinence Care policy revised in December 2012 included under procedure assist to side lying position by turning toward caregiver, unless more than one caregiver present. After turning patient toward care giver, assure patient is positioned in the center of the bed before moving to the opposite side of the bed to provide care. On 06/12/15 a bed positioning plan of care was inserviced. The October 2011 Bed Positioning policy indicated under procedure to verify transfer assist per Kardex. Obtain additional assistance as indicated. On 08/12/15 at 9:26 A.M. STNA #50 indicated Resident #21 had been a two assist for a long time because of his size and weight. STNA #50 indicated the STNA care information was in the Kiosk. On 08/12/15 at 9:51 A.M., interview with Registered Nurse (RN) #44 indicated that she gathered the information for documenting functional abilities by talking to the STNAs and therapy staff and the information provided in the Kiosk. RN #44 indicated that she also spoke to the resident. RN #44 indicated the ADL living task list summary indicated that Resident #21 was an assist of one or two for ADL's. RN #44 indicated that meant the resident would be assist of one for some tasks such as eating but for other tasks needed assistance of two. RN #44 indicated she would never turn Resident #21 herself. On 08/12/15 at 10:14 A.M. the Director Of Nursing indicated Resident #21 was an ADL of one to two. She verified the task summary indicated ADL assist - extensive assist to dependent of 1-2 staff did not specify which ADL's were one assist and which were two assist.

Based on observation, record review and interview the facility failed to implement an individualized and effective pain management program for Resident #134 and failed to adequately assess and monitor wound healing for Resident #96. Harm occurred to Resident #134 when the facility failed to reorder pain medication, which staff had assessed was the only intervention which relieved the resident's pain, resulting in the resident experiencing pain equivalent to the worst pain she had experienced in the past. This affected two residents (Resident #96 and #134) of 25 residents reviewed for provision of care, including pain management and non-pressure related skin impairment. Findings include: 1. Review of Resident #134's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A pain assessment dated [DATE] indicated Resident #134 had back problems. The pain onset was greater than six months. Resident #134 characterized her pain as intermittent. She reported frequent pain over the prior five days, was unable to determine a specific time of day which pain occurred, and was unable to determine a specific event causing pain. A note indicated Resident #134 had a history of [REDACTED].#134 utilized a narcotic pain medication, [MEDICATION NAME] but recently changed to [MEDICATION NAME] which the resident reported was effective. The location of the pain was identified as her lower back. Resident #134 reported her pain at the time of the assessment was five on a scale of 0 - 10. Her pain at the best was rated five and the resident's pain goal was five. Resident #134 described her pain as aching and identified exacerbating factors as bending and position changes. Resident #134 identified medication as the only relieving factor and reported that pain negatively affected her activities of daily living, standing, walking, sitting, activities, sleep and depression. Resident #134 indicated prescription medication was effective but over the counter medication was not. Resident #134 reported no non-pharmacological interventions were effective with pain control/relief. Resident #134 stated [MEDICATION NAME] was the only thing effective for her. During the assessment, Resident #134 indicated pain occurred frequently on a daily basis. At its worse, she rated pain a nine on a scale of 0-10. Pain at its best was a five or six and was tolerable at that level and was her goal. On 05/18/14 at 10:02 A.M., Resident #134 yelled out into the hallway as a member of the survey team was passing her room, asking if the surveyor was her nurse. Resident #134 reported she had been waiting on a pain pill for two hours and requested her nurse be found and told she wanted her pain medication. Registered nurse (RN) #23 was standing near the nursing station and was asked if she knew where Resident #134's nurse was. RN #23 pointed to licensed practical nurse (LPN) #24 who was on the telephone. The message related to Resident #134's request for pain medication was relayed to RN #23. At 10:05 A.M., LPN #24 walked down the hall and stated she was trying to get a hold of pharmacy. On 05/18/14 at 10:20 A.M., State tested nursing assistant (STNA) #25 was interviewed and stated STNA #11 responded to Resident #134's call light earlier and the resident requested a pain pill but she was only aware of the resident calling one time. On 05/18/14 at 10:22 A.M., STNA #11 was interviewed and stated she had only answered Resident #134's call light once that morning around 9:00 A.M. and the resident requested a pain pill. STNA #11 stated she reported this to LPN #24 as soon as she saw her, within five minutes of the request. On 05/18/14 at 10:25 A.M., Resident #134 was interviewed and stated she still had not received pain medication and had been waiting since 8:00 A.M. Resident #134 stated she had three back operations and rated her pain a nine on a scale of zero to ten. Resident #134 stated she had taken pain medication for years and she was not sure what the problem was. Resident #134 stated the nurse did talk to her after she requested the surveyor go out and ask about pain medication. The resident stated the nurse told her she was waiting on the pharmacy to fax something because her pills ran out. On 05/18/14 at 10:30 A.M., LPN #24 was interviewed and stated Resident #134 needed a new prescription and had no [MEDICATION NAME] (narcotic pain medication) left. LPN #24 stated nurses normally reordered medication when there were ten to 15 pills remaining. Review of the medication administration record (MAR) with LPN #24 revealed Resident #134 usually took the medication at 8:00 A.M. and 2:00 P.M. every day although it was ordered on an as necessary basis. LPN #24 stated she would attempt to learn when the refill order had been sent to the pharmacy. LPN #24 stated staff would not know the resident needed a new prescription unless pharmacy told them. The order on the MAR read: [MEDICATION NAME] 5/325 one tablet three times a day as necessary. The last administered dose was recorded on the MAR as 2:00 P.M. on 05/17/14. On 05/18/14 at 11:20 A.M., LPN #24 stated she spoke with pharmacy and learned when Resident #134 was admitted on [DATE], 15 tablets of [MEDICATION NAME] were sent to the facility. When she contacted the pharmacy the morning of 05/18/14, LPN #24 was informed Resident #134 needed a new prescription for the [MEDICATION NAME]. The physician was informed after LPN #24 spoke to pharmacy. LPN #24 stated nursing did not know when a resident needed a new prescription until pharmacy notified them. At 12:12 P.M., LPN #24 stated she found the sticker had been pulled to re-order Resident #134's [MEDICATION NAME] but the pharmacy's website had been down for two days so it was unable to be ordered prior to that morning. LPN #24 stated she was unsure if any of the nurses had phoned the pharmacy to re-order the medication due to the system not working. On 05/20/14 at 8:40 A.M., the director of nursing (DON) was interviewed and verified the administration of all 15 doses of the [MEDICATION NAME] delivered on 05/12/14 were not recorded on the MAR. The DON verified Resident #134 had been receiving three doses of the [MEDICATION NAME] every day. The DON stated nurses scanned re-ordered medications to the pharmacy and if they were unable to scan the information, the nurses should have called the pharmacy. On 05/20/14 at 11:34 A.M., DON was again interviewed and stated she was unable to find any additional information from pharmacy regarding if there had been any phone calls to order the [MEDICATION NAME] prior to the resident's supply running out. The pharmacy did not record phone calls. 2. Resident #96 was admitted [DATE] with [DIAGNOSES REDACTED]. Resident #96 was observed on 05/19/14 at 3:16 P.M. Resident #96 was in bed, asleep. An open sore was observed on the right side of the resident's face, near the jaw line. The wound was exposed, bright red with a moderate amount of dried blood on the surrounding tissue. An interview was completed with RN #12 at the time of the observation. RN #12 said the wound began as a boil, came to a head and opened. RN #12 said Resident #96 had a history of [REDACTED]. Recently, Resident #96 had a cold sore on her lip and the doctor believed it could be related. RN #12 said he believed Resident #96 was on medication for the wound. An interview was completed with LPN #91 on 05/19/14 at 3:35 P.M. LPN #91 said Resident #96 was on, [MEDICATION NAME] 800 milligrams (mg) four times a day. [MEDICATION NAME] is an [MEDICAL CONDITION] medication used to treat [MEDICAL CONDITION]. LPN #91 said [MEDICAL CONDITION] started out as a small cold sore on the Resident's lip. Resident #96 was "picking at it and would not leave it alone". LPN #91 said "overnight the sore became so bad it looked like she was punched in the mouth". LPN #91 said the lip wound resolved but the doctor continued the [MEDICATION NAME] because he believed the face wound was related. A second observation was completed on 05/20/14 at 8:29 A.M. Resident #96 was lying on her bed. Resident #96 was awake and alert. A small amount of active bleeding was observed on the face wound. Blood was observed on the resident's shirt, near the wound. The wound and surrounding tissue was red. Review of a current physician order [REDACTED]. Record review revealed no assessment or monitoring of the face wound. An interview was completed on 05/20/14 at 11:32 A.M. with RN #12. RN #12 verified there was no evidence of wound assessment and monitoring. RN #12 revealed he was not aware Resident #96 picked at the wound. Review of a wound assessment and physician order, obtained following the interview and dated 05/20/14, described the wound as dark pink/red tissue measuring 0.4 centimeters (cm) by 0.3 cm with less than 0.1 cm depth. The new order required cleansing the wound with wound cleanser, applying triple antibiotic ointment and covering the wound with a band-aid. The dressing was to be changed daily.