Every finding on record at Valley Vista Care Center of St Maries

Based on record review, interview, and policy review, the facility failed to ensure two of two residents and their resident representatives (Resident (R) 8, and R52) reviewed for emergent hospital transfer out of a total sample of 18 residents were provided with a written bed hold policy and transfer notice. This failure had the potential to affect the resident and their resident representative (RR) by not having the knowledge of how to appeal the transfer, if desired, and had the potential to contribute to the possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. Findings include:1. Review of R8's admission Record, located under the Profile tab in the electronic medical record (EMR), revealed R8 admitted to the facility on [DATE]. Review of R8's quarterly 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], located in the EMR MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated severely impaired cognition.Review of R8's Progress Note, located in the EMR Progress Notes tab and dated [DATE], revealed that R8 was transferred to the hospital due to abnormal critical labs and returned to the facility on [DATE]. According to documentation the facility called a contact on file and left a message to return call to the facility. R8's Power of Attorney (POA) did return the call. The was no documentation that the transfer notice and bed hold were provided. 2. Review of R52's admission Record under the Profile tab in the EMR revealed R52 admitted on [DATE]. Review of R52's Medicare 5-day MDS, located in the EMR MDS tab, with an ARD of [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition.Review of R52's Progress Note, located in the EMR Progress Notes tab and dated [DATE], revealed that R52 was transferred to the hospital due to uncontrollable pain and returned to the facility on [DATE]. The was no documentation that the transfer notice and bed hold were provided.Review of R52's Progress Note, located in the EMR Progress Notes tab and dated [DATE], revealed that R52 was transferred to the hospital with shortness of breath (SOB), tremors to both arms, and oxygen saturation levels below 88%. R52 later expired at the hospital. According to documentation, the family was notified. The was no documentation that the transfer notice and bed hold were provided. During an interview on [DATE] at 2:00 PM, the Administrator confirmed that they had not sent the bed hold notices for R8 and R52.Review of the facility's policy Transfer and discharge date d [DATE] revealed, .Contents of written notice:1. The written notice of transfer/discharge includes:g. Reason for transfer/ dischargeh. Effective date of transfer/ dischargei. Location to which the resident is transferred/ discharged j. Statement that the residents have the right to appeal the action to the state.k. Name, address and telephone number of the state long term care ombudsman, andl. As applicable, mailing address and telephone number of the agency responsible for protection and advocacy of developmentally disabled or mentally ill individuals.m. Sends a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.Review of the facility's policy Bed-Holds and Returns dated [DATE] revealed, . Residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents regardless of payor source, are provided with written notice about these twice: a. notice 1: well in advance of any transfer (e.g., in admission packet): and b. notice 2: at the time of transfer (or if the transfer was an emergency, within 24 hours).

Based on observation, interview, record review, and facility policy, the facility failed to provide assistance with showering for two of three residents (Resident (R) 45 and R16) reviewed for activities of daily living (ADLs) out of a total sample of 18. This failure increased the potential for R45 and R16 to have unmet hygiene needs.Findings include:1. During initial rounds on 05/05/26 starting at 11:00 AM an observation of R45 revealed R45 appeared to have flaky skin, and her hair appears greasy and in need of a wash.During an interview on 05/05/26 at 1:50 PM, Family Member (F) 1 stated, R45 was not getting showers. F1 stated R45 was supposed to get three showers/baths per week but she's lucky to get one. F1 stated staff were not getting R45 dressed in the mornings. F1 presented a calendar to writer that the family was documenting showers R45 received. F1 stated that R45 only received four showers total for the month of April.Review of R45's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R45 was admitted to the facility on [DATE] with diagnoses that included Type 3 traumatic spondylolisthesis (displacement of vertebra) of 2nd cervical vertebra fracture routine healing, unspecified dementia, and spinal stenosis cervical region (abnormal narrowing of the spine).Review of R45's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/16/26, located under the MDS tab of the EMR, revealed R45 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated R45 had moderate cognitive impairment. It was recorded R45 required substantial/maximal assistance for showering/bathing. No documentation of refusing care.Review of R45's care plan, located in the EMR under the Care Plan tab, dated 08/06/24, revealed R45 had an ADL self-care performance deficit related to impaired balance, limited mobility, limited range of motion (ROM), and pain in neck. Further review of the care plan, revealed no recorded concerns with rejection of care related to ADLs, including showering, nor that the resident only responded to questions in the negative.2. During initial rounds on 05/05/26 starting at 11:00 AM an observation of R16 revealed R16's hair appeared to need to be washed, her hair was waist length and appeared greasy at the crown of head.During an interview on 05/05/26 at 3:10 PM, R16 stated, I'm not getting my showers or baths, I'm supposed to get three a week, I'm lucky if I get one. They say they are short-staffed, but they're sitting around.During an interview on 05/06/26 at 9:30 AM, R16 stated, They won't give me a shower. They say they don't have a bath team. Review of R16's admission Record, located in the EMR under the Profile tab, revealed R16 was admitted to the facility on [DATE] with diagnoses that included Quadriplegia C5-C7, Bipolar disorder, spinal stenosis. Review of R16's quarterly MDS with an ARD of 04/15/26, located under the MDS tab of the EMR, revealed R16 had a BIMS score of 15 out of 15, which indicated R16 was cognitively intact. It was recorded R16 required partial/moderate assistance for showering/bathing. No documentation of refusing care. Review of R16's care plan, located in the EMR under the Care Plan tab, dated 11/03/23, revealed R16 had an ADL self-care performance deficit related to incomplete quadriplegia. Further review of the care plan, revealed no recorded concerns with rejection of care related to ADLs, including showering, nor that the resident only responded to questions in the negative.During an interview on 05/08/26 at 3:00PM, the Director of Nursing (DON) and Administrator revealed they were aware that staff members felt they were short-staffed if there was not a bath team. They stated the certified nurse aides (CNAs) were unaccustomed to giving baths to their residents and did not give baths or groom residents if the bath team was unavailable. They stated that the prior DON never had room assignments for CNAs they all looked after all residents so there was no accountability. The DON stated that since she arrived about six weeks ago, CNAs had assigned rooms and were being held accountable for their residents' care.Review of the facility's policy titled, Activities of Daily Living, Documentation Flow Sheet, last revised April 2025, revealed, Residents are provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.The refusal and details of the interventions refused are documented in the resident's clinical record.

Based on observation, staff interviews, and policy review, the facility failed to discard expired medications stored in one medication room storage refrigerator of one medication room. This deficient practice resulted in outdated medications remaining available for use. Findings include:Observation of the medication storage room refrigerator with the Minimum Data Set Coordinator (MDSC) on 05/07/26 at 11:35 AM revealed the following medications were expired. -One Lispro Insulin 100 units/milliliter (ml) vial had an expiration date of 01/23/26. There was no open date on the vial. -One Lantus Insulin 100 units/ml vial had an expiration date of 01/23/26. There was no open date on the vial. -One Apidra Solostar Insulin 100 units/ml injection pen had an expiration date of 02/04/26. -Trulicity (medication used to manage blood sugar levels) 3 milligrams (mg)/0.5 ml injection pen had an expiration date of 01/16/26 (Two injection pens left in the carton of four). There was no open date on the medication carton. -Gabapentin (anticonvulsant medication for seizures and pain) 250 mg/5ml solution (a 500 ml bottle with 450ml remaining) had an expiration date of 10/02/23. There was no open date on Gabapentin bottle. During an interview at the time of observation, the MDSC confirmed the medications stored in the storage refrigerator were expired and stated Licensed Practical Nurse (LPN) 1 was responsible for monitoring medication expiration dates for medications stored in the storage refrigerator. During an interview 05/07/26 at 12:59 PM, the Director of Nursing (DON) stated she did not think that anyone was assigned to go over the medication storage refrigerator and check for expired medications. The DON further stated that in the future a routine system to remove expired medications would be in place. The DON stated the expired medications should have been destroyed by staff or returned to the pharmacy for disposal.During an interview on 05/08/26 at 2:40 PM, LPN1 stated she reviewed all medication carts for expired medications but did not check the medications stored in the refrigerator. Review of the facility's policy titled, Administering Medications with revision date of April 2019 indicated, Medications are administered in a safe and timely manner, and as prescribed, under item 12, indicated the expiration/beyond use date on the medication label is checked prior to administration. When opening a multi-dose container, the date opened is recorded on the container.Review of the facility's policy titled, Discarding and Destroying Medications with revision date June 2025 indicated, under item 8, indicated for unused, non-hazardous controlled substances not disposed of by an authorized collector the EPA [Environmental Protection Agency] recommends destruction and disposal of the substance with other solid waste. Review of the facility's undated policy titled, Medication Labeling and Storage, indicated, under Medication Storage item 3, if the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Under Medication Labeling under item 5, it is indicated that . are dated or discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. Under item 6, indicated multi-dose vials that are not opened or accessed are discarded according to the manufacturer's expiration date.

Based on policy review, record review, review of the State Survey Agency's Long-Term Care Reporting Portal, and staff interview, it was determined the facility failed to ensure residents' rights were protected to be free from abuse and neglect. This was true for 6 of 16 residents (Residents #5, #24, #36, #299, #300, and #349) reviewed for abuse and neglect. This failure placed all residents at risk of ongoing abuse and neglect, and potential physical and psychosocial harm. Findings include: 1. A facility reported incident investigation, initiated 7/9/23, documented CNA #4 and CNA #5 did not empty Resident #5's catheter bag during the 7/8/23 night shift. As a result, the staff on the following day shift found her catheter bag was backed up to her bladder with more than 3000 milliliters (mls) of urine. During the facility's investigation, the staff assigned to Resident #5's unit were interviewed: CNA #4, a facility CNA, stated she did not provide cares for Resident #5 during the 7/8/23 night shift since Resident #5 had previously refused to allow CNA #4 to provide her cares. CNA #4 stated she thought LPN #8 and CNA #6, a float CNA, provided cares for Resident #5 during the night shift. Additionally, she stated CNA #5 told her Resident #5's catheter care was completed. CNA #4 stated she would have notified the nurse if Resident #5's call light was activated, and she did not remember Resident #5 using her call light during the night of 7/8/23. CNA #5, an agency CNA, was asked if she provided cares for Resident #5 during the 7/8/23 night shift. She stated, I do not go in her room, she hates me. The float was there until 10 PM. Once in bed she doesn't get up until 5:30 AM, I don't go in there, I do not know if someone else was in there through the night. When asked if she ignored Resident #5's call light if no one else was around to help her, she stated, Yes, if nobody was around to do it I am not going in there. When asked why she did not make sure other staff were brought over from another unit to help Resident #5, she stated, Once [Resident #5] is in bed she does not wake until morning so no need. Additionally, CNA #5 confirmed she documented on 7/9/23 at 4:57 AM that Resident #5's catheter was emptied of 600 mls. She stated she found the information on a paper she assumed was left by another staff member who put Resident #5 to bed on 7/8/23. The investigation did not note who documented the catheter care on the paper CNA #5 claimed she saw. LPN #8 stated that neither CNA #4 nor CNA #5 asked her to check on Resident #5 during the shift. When asked who emptied Resident #5's catheter during the night shift, she stated the day shift CNAs told her 600 mls were charted by the night shift CNAs. Resident #5's care plan did not include measures to restrict CNA #4 or CNA #5 from providing care to her. The investigation substantiated neglect for Resident #5. The incident report documented the following interventions: - Termination of employment for CNA #5 - Reeducation of abuse/neglect for CNA #4 and was no longer to be assigned to Resident #5's unit. - In service training related to abuse/neglect for all staff was conducted The facility Administrator was interviewed on 11/29/23 at 3:37 PM, and Resident #5's incident report was reviewed in his presence. He confirmed the facility did not ensure Resident #5 was free from neglect. 2. A facility reported incident investigation, initiated 4/3/23, documented 3 CNAs did not report 2 residents' falls (Resident #24 and Resident #300) on 4/2/23. As a result, the 2 residents were not immediately assessed by a nurse for injuries. During the investigation, the following interviews were conducted: The facility's Unit Manager stated she received a telephone call on 4/3/23 from CNA #11 informing her 2 resident falls occurred on the 4/2/23 night shift and were not reported to the nurse. The Unit Manager stated she immediately reported the incidents to the Administrator and the former DNS. CNA #11 stated that, around 8:00 PM on 4/2/23, she observed Resident #300 on the floor near the nurses' station with CNA #9. She stated that she told CNA #9 that she was going to get the nurse and CNA #9 told her, No, let's get her [Resident #300] up. CNA #11 stated that, later that evening, during her break around 11:00 PM, CNA #9 told her that Resident #24 had fallen in her room and was put back in bed. CNA #11 stated, I've been kicking myself for not reporting it. When asked about the falls, CNA #9 stated on 4/2/23, CNA #10 called her to assist Resident #300 to a chair after she had fallen. CNA #9 stated CNA #11 said they needed to do a report stating Resident #300 had bumped her arm. CNA #9 stated she told CNA #11 not to do a report. Additionally, she stated she assisted CNA #10 with putting Resident #24 in her bed after she had fallen. CNA #9 stated she did not report the falls since the staff were too busy providing one-to-one supervision of two other residents and did not have time to provide additional supervision (according to fall protocols) of Resident #24 and Resident #300. When asked if unreported falls had occurred on 4/2/23, CNA #10 initially said no. When specifically asked if Resident #24 and Resident #300 had fallen on 4/2/23, CNA #10 stated, I'm going to be honest with you, I'm not sure on [Resident #300], but [Resident #24] was on the floor, yes. She later provided a written statement in which she admitted she was present when Resident #300 fell near the nurses' station and assisted CNA #9 with moving her to a chair. Additionally, she stated CNA #9 called her to Resident #24's room to help her get Resident #24 back to her bed after her fall. When asked why the falls were not reported, she stated, We were worried about getting in trouble. There was a lot happening, and we were not staffed appropriately and didn't want to lose our jobs. It was a mutual decision. The investigation substantiated neglect for Resident #24 and Resident #300. The incident report documented the following interventions: - On 4/3/23, Resident #24 was assessed by a nurse and no physical or psychosocial injuries were found. - On 4/3/23, Resident #300 was assessed by a nurse and no physical or psychosocial injuries were found. - CNA #9, CNA #10, and CNA #11 were terminated from employment at the facility. - Facility-wide training was conducted for all staff. The facility Administrator was interviewed on 11/29/23 at 3:37 PM, and the incident report for Resident #24's and Resident #300's unreported falls was reviewed in his presence. He confirmed the facility did not ensure Resident #24 and Resident #300 were free from neglect when their falls were not reported to a nurse to provide assessments and interventions. 48402 3. A facility reported incident, dated 2/16/22, documented RN #2 neglected to administer medications to Resident #5, Resident #36, and Resident #299. The facility's incident report, dated 2/16/22, documented a review of 5 resident records was conducted. During the review 3 of 5 residents were identified to have a discrepancy between the MAR and the reconciliation of narcotic medication. Resident #5's record was identified to have a discrepancy with 1 narcotic administration. Resident #36's record was identified to have discrepancy with 4 narcotic administrations. Resident #299's record was identified to have a discrepancy with 1 narcotic administration. The facility incident report included 3 staff statements. RN #2's statement stated she was unaware of the medication errors she had made. LPN # 1's statement stated she had trained RN #2 but during the training she was observed to make multiple mistakes. CNA #2's statement stated Resident #36 was short tempered and very uncomfortable when cares were provided during that time. The facility concluded this investigation was substantiated for neglect. The facility's incident report documented residents were placed on charting to monitor for changes in pain management, education was provided to nurses on medication administration procedures, audits of MAR and narcotic books were conducted, and RN #2 was terminated. 4. A facility incident report, submitted 4/23/22, to the State Agency's Long-Term Care Reporting Portal, documented an allegation was reported to a nurse that Resident #349 was sitting in a chair at the end of the CCU (Complex Care Unit) hall. Resident #36 came over and sat in Resident #349's lap. When Resident #36 sat in his lap, Resident #349 grabbed her breast. The report included staff members statements. Two staff members stated they did not see the interaction between both residents. One staff member reported seeing Resident #36 walk over and sit on Resident #349's lap. Resident #349 proceeded to put his hand up her shirt and touch Resident #36's breast. She stated she called out to both residents, but it was too late. She immediately separated the residents and notified the nurse. The incident report also documented both residents were assessed, and no injuries were identified. The facility's incident report concluded this was an abuse incident. Interventions implemented were increased supervision, reminders of boundaries, and maintaining both residents within line of sight. 5. A facility investigation report, submitted 5/27/23, to the State Agency's Long-Term Care Reporting Portal, documented Resident #18 walked up to Resident #300 and kissed her on the mouth unexpectedly. The report documented the LPN on shift witnessed the incident and separated both residents. The report included interventions for both residents to be supervised in common areas as well as 15-minute checks for Resident #18 for 72 hours. The report included a statement from Resident #18 acknowledging the incident did occur. The report documented the facility concluded the incident was abuse.

Based on policy review, record review, review of the State Survey Agency's Long-Term Care Reporting Portal, and staff interview, it was determined the facility failed to ensure allegations of abuse were thoroughly investigated. This was true for 6 of 16 residents (#36, #298, #300, #348, #349, and #350) reviewed for abuse. This failure created the potential for residents to be subjected to ongoing abuse without detection and protective measures implanted by the facility. Findings include: The facility's Reducing the Threat of Abuse and Neglect policy, revised December 2022, stated an alleged abuse or neglect investigation should include the following: - Review of the incident - Interview with the person reporting the incident - Interviews with any witnesses to the incident - Interview with the resident - A review of the resident's medical record - An interview with employee(s), as needed - A review of employee's file, as needed. - Interview with staff members on all shifts having contact with the resident at the time of the incident. - Interview with the resident's roommate, family or visitors who may have information. - Interview other residents who received care or services from the alleged perpetrator. - A review of all circumstanced surrounding the incident. a. A facility incident report, submitted 4/23/22, to the State Agency's Long-Term Care Reporting Portal, documented an allegation was reported to a nurse that Resident #349 was sitting in a chair at the end of the CCU (Complex Care Unit) hall. Resident #36 came over and sat in Resident #349's lap. When Resident #36 sat in his lap, Resident #349 grabbed her breast. The report included staff members statements who stated they did not see the interaction between the residents. One staff member reported seeing Resident #36 walk over and sit on Resident #349's lap. Resident #349 proceeded to put his hand up her shirt and touch Resident #36's breast. She stated she called out to both residents, but it was too late. She immediately separated the residents and notified the nurse. The incident report also documented both residents were assessed, and no injuries were identified. The facility's incident report concluded this was an abuse incident. Interventions implemented were increased supervision, reminders of boundaries, and maintaining both residents within line of sight. The facility's investigation did not include additional resident interviews or staff interviews to ensure other residents were not experiencing sexual abuse. b. A facility investigation report, submitted 5/27/23, to the State Agency's Long-Term Care Reporting Portal, documented Resident #18 walked up to Resident #300 and kissed her on the mouth unexpectedly. The report documented the LPN on shift witnessed the incident and separated both residents. The report included interventions for both residents to be supervised in common areas as well as 15-miute checks for Resident #18 for 72 hours. The report included a statement from Resident #18 acknowledging the incident did occur. The report documented the facility concluded the incident was abuse. The facility's investigation did not include witness interviews to ensure other residents were not experiencing sexual abuse. c. A facility investigation report, submitted 2/6/22, to the State Agency's Long-Term Care Reporting Portal, documented an LPN reported Resident #18 hit Resident #298 in the back of the head. Both residents were separated and assessed for injuries. No injuries were identified. Resident #18's statement stated he had no memory of hitting Resident #298. Resident #298 stated she could not recall the incident. The facility's incident report concluded abuse did occur. The facility's investigation did not include resident interviews to ensure other residents in the facility were not experiencing abuse. d. A facility investigation report, submitted 2/20/22, to the State Agency's Long-Term Care Reporting Portal, documented Resident #348 reported Resident #351 entered her room and told Resident #348 to get out of the room. When Resident #348 did not leave the room Resident #351 became agitated and slapped her on her left arm. The investigation documented Resident #351 did not recall the incident. The facility concluded abuse did occur. Resident #348 was monitored for injuries and Resident #351 was assessed for a higher level of care. The facility's investigation did not include resident interviews to ensure residents in the facility were not experiencing abuse. e. A facility investigation report, submitted 4/27/22, to the State Agency's Long-Term Care Reporting Portal, documented Resident #347 was agitated and walked into Resident #350's room and slapped her right arm twice. Staff immediately redirected Resident #347. One CNA's statement documented she was following Resident #347 into the room but was not able to stop her from hitting Resident #350. The facility concluded abuse did occur. Both residents were assessed for injuries. Resident #347 was to have 1:1 staff supervision and to redirect her when she was within arm's length from others. The facility's investigation did not include resident interviews to ensure other residents in the facility were not experiencing abuse. f. A facility investigation report, submitted 5/17/22, to the State Agency's Long-Term Care Reporting Portal, documented Resident #347 was walking past Resident #298 in a common area when she reached out and hit Resident #298 on the back of her head. Both residents were assessed, and no injuries were noted. The incident report included 1 CNA and 1 LPN interview who stated they looked up and saw Resident #347 hit Resident #298. Both Resident #347 and Resident #298 stated they did not recall the incident. The facility concluded this was an incident of abuse and monitored both residents following the incident. The facility's investigation did not include resident interviews to ensure residents in the facility were not experiencing abuse. On 11/29/23 at 4:33 PM, the Administrator stated he did not interview additional residents during the investigations because the residents in the behavioral unit are not cognitively intact and would not know if they witnessed abuse or neglect. He also stated he was not able to conclude if any additional residents were involved in any of the investigation's because he did not ask.

Based on observation, record review, and staff interview, the facility failed to ensure resident-centered care and treatment were provided timely and bowel care administered per physician orders in accordance with professional standards of practice. This was true for 2 of 23 Residents (#25 and #352) whose records were reviewed. These failures caused harm to Resident #352 when there was a delay in treatment and subsequent decline in her health and put Resident #25 at risk of adverse effects when she did not receive bowel care as ordered. Findings include: 1. Resident #352 was readmitted to the facility on [DATE] with multiple diagnoses including dementia with behavioral disturbances. Resident #352's care plan, documented she was cognitively impaired due to her dementia and staff were to provide a consistent daily routine. A nurse's note, dated 1/15/22 at 4:32 AM, documented Resident #352 was repeatedly yelling help me and having visual hallucinations. The note also documented Resident #352 had a fever of 104.1 degrees (normal temperature is 98.6 - 100.4) Resident #352's record did not include documentation Resident #352's physician and representative were notified of her change in condition. A nurse's note, dated 1/15/22 at 12:33 PM, documented Resident #352 had escalated behaviors, yelling out for help but unable to verbalize what she needed. The physician was notified (approximately 8 hours after the note documenting her hallucinations and fever) and a new order for Fosfomycin (an antibiotic commonly used for urinary tract infections) was ordered along with labs. The nurse's note documented the family was notified of the physician orders. A nurse's note, dated 1/16/22 at 2:17 AM, documented Resident #352 was yelling and calling out mother of God help. The nurse's note documented Resident #352's oxygen saturation (percentage of oxygen in the blood) was 88% (normal is 95% - 100%). Resident #352's record did not include a notification to family or the physician about her change in condition. A nurses note, dated 1/16/22 at 7:32 AM, documented at approximately 5:15 AM Resident #352 was restless, uncomfortable, and unable to follow directions. The nurse documented Resident #352's pulse was 130 (normal range is 60 to 100) and very irregular. Resident #352's family and physician were notified (more than 5 hours after the note documenting her decreased oxygen saturation). The physician gave an order to send her to the hospital for further evaluation. A hospital visit summary, dated 1/16/22 at 8:52 PM, documented Resident #352 was to be transferred to the emergency department on 1/15/22 (1 day prior) but did not arrive. The hospital summary documented Resident #352 had a primary diagnosis of urinary tract infection as well as cellulitis (bacterial skin infection) to her left lower leg. The physician notified Resident #352's representative of her prognosis. Resident #352's representative agreed comfort measures were appropriate at that time. On 1/17/22 at 12:32 PM, a nurses note documented Resident #352 was found with no heart and lung sounds. On 11/30/23 at 2:38 PM, upon review of Resident #352's record, the Administrator stated no documentation was in Resident #352's record stating why there was a delay of treatment. 15879 2. The facility's Bowel Protocol, revised 9/2017, documented the following standing orders for constipation: Use one of the following as needed if a resident has no stool by the following days: - Day 3: Administer Milk of Magnesia 30 cc orally. If the first dose is ineffective, may give one additional dose after 6 hours if no stool. - Day 4: Administer a Dulcolax suppository 10 mg per rectum. - Day 5: If resident refuses all interventions days 3-5 administer a saline enema. If no stool after enema; notify the physician, place on alert charting, every shift, and monitor for [bowel] obstruction. This protocol was not followed. Resident #25 was admitted on [DATE] and readmitted on [DATE], with multiple diagnoses including post operative orthopedic care following surgical amputation of her left lower leg. An MDS assessment, dated 10/20/23, documented Resident #25 had moderately impaired cognition, was always incontinent of bowel and bladder and received routine and as needed pain medications. A physician order, dated 10/19/23, documented to administer Miralax (a stool softener), 17 grams per scoop to Resident #25 one time a day for constipation. The order also documented to administer Senna Docusate Sodium (stool softener) 8.6 - 50 mg, two tabs twice a day for constipation. Milk of Magnesia (stool softener) 20 ml was to be given as needed for bowel management if Resident #25 did not have a bowel movement in three days and may be repeated after six hours if no bowel movement. Dulcolax (stool softener) rectal suppository 10 mg, was ordered to be inserted rectally every 24 hours as needed for constipation. Sodium Phosphate (stool softener) rectal enema was also ordered every 24 hours as needed for constipation. The order further directed staff to follow the facility's bowel protocol. Resident #25's care plan, revised 10/31/23, documented she had difficulty with elimination and directed staff to follow facility bowel protocol as follows: - Day 3 no stool: administer Milk of Magnesia - Day 4 no stool: administer suppository - Day 5 no stool: administer enema and notify the physician Resident #25's care plan further documented she had pain and one of the interventions was to monitor for constipation. A documentation report for bowel elimination, dated 11/2023, documented Resident #25 did not have a bowel movement from 11/3/23 through 11/8/23 (5 days) and from 11/22/23 through 11/25/23 (3 days). Resident #25's November 2023 MAR, documented Milk of Magnesia was administered on 11/7/23, 5 days from her last recorded bowel movement. Her next bowel movement was on 11/9/23, 7 days from her last recorded bowel movement. Resident #25's MAR did not include documentation other as needed bowel medications were administered after the first dose of Milk of Magnesia did not render results within six hours. The MAR further documented a Dulcolax suppository was administered on 11/19/23. Resident #25's MAR did not include additional ordered as needed medications were administered for constipation from 11/22/23 through 11/25/23. During an interview on 11/30/23 at 4:29 PM, LPN #5 stated she ran the laxative list daily, which documented which residents needed an intervention for constipation, usually after three days of no bowel movement. LPN #5 stated the nurses on the units knew how to run the report when she was not there, and they were expected to run the report every morning. LPN #5 stated she would let the nurses know who needed an intervention, but they should also run the report. LPN #5 stated the protocol was if a resident did not have a bowel movement for three days, Milk of Magnesia was to be given and if no results in six hours, the Milk of Magnesia could be repeated. She further stated for day four, Dulcolax was to be given and on day five an enema was to be given and the physician was to be called. LPN #5 stated Resident #25 should have had the protocol for constipation followed, and that did not happen. LPN #5 stated she did not see where Resident #25 refused any medication for constipation. The laxative list, provided by LPN #5, documented Resident #25 was on the list for 11/6/23 through 11/8/23. The laxative list for 11/22/23 through 11/25/23 did not include Resident #25, although records indicated she did not have a bowel movement in that time span. During an interview on 11/30/23 at 4:29 PM, LPN #5 stated she was on vacation from 11/22/23 through 11/25/23. LPN #5 stated not following bowel movement protocol was not acceptable and it put Resident #25 at risk for bowel obstruction. During an interview on 11/30/23 at 5:12 PM, LPN #2 stated she ran the laxative list that morning and it let her know who had not had a bowel movement in three days and to give them Milk of Magnesia. LPN #2 further stated, if there were no results from the Milk of Magnesia, they were to administer a suppository. She stated if the suppository was not effective, they would call the physician to get an order for an enema. LPN #2 stated if a resident had a physician order, then the order should be followed.

Based on facility document review and staff interview, it was determined the facility failed to ensure they employed an RN as the full-time DNS. The failure to have a full-time RN/DNS placed residents at risk of inadequate care and supervision of their medical status for a census of 44 residents. Findings include: The facility's job description for the Director of Nursing Services, approved by the Administrator on 3/9/20, documented Responsible for the management of the nursing services in the long-term care facility and directs nursing activities . The essential duties and responsibilities included the following: The DNS has knowledge of the state and federal regulations in the delivery of resident care, is informed of residents' conditions, determines the facility capacity for the care of potential new admissions, maintains the Quality Assurance program, ensures medications, treatments and plans of care are provided to the residents, evaluates nursing care by making daily rounds of the facility, and ensures adequate staff are available for resident care. During an interview on 11/29/23 at 10:10 AM, the Administrator stated there was no full-time RN designated to be the DNS working full-time at the facility and involved in resident care. During an interview on 11/30/23 at 10:30 AM, the Corporate Human Resources Director confirmed the facility did not have a full-time DNS.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure food items were dated and labeled and hygiene practices followed. This failure had the potential to affect 44 of 44 residents residing in the facility who consumed food prepared by the facility at risk of adverse health outcomes, including food-born illnesses. Findings include: 1. The facility's Food Storage policy, undated, stated once products were opened, a use by date label must be added. This policy was not followed. On 11/27/23 at 4:00 PM, during a kitchen inspection, 7 of 18 seasoning containers appeared cloudy and moist. 7 of the 18 opened seasoning containers did not have a use by date on the container. On 11/27/23 at 4:09 PM, The Dietary Manager stated the opened seasoning containers should have a use by date, and they did not. 2. The facility's Preventing Foodborne Illness policy, revised November 2022, stated hair caps and beard restraints were worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, and utensils. This policy was not followed. On 11/28/23 at 10:52 AM, the Dietary Aid was observed in the kitchen assembling meal trays with no cover over his mustache. On 11/28/23 at 11:15 AM, the Dietary Aid stated he was never told the beard restraint should be worn to cover his mustache. On 11/28/23 at 11:17 AM, the Dietary Manager stated the beard restraint should be worn above the mustache to prevent hair from falling onto the meal trays.

Based on interview and document review, it was determined the facility's administration failed to ensure a full-time DNS was on staff. This failure had the potential to affect the care of the 44 residents in the facility and the assistance and care needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings include: During an interview on 11/29/23 at 10:10 AM, the Administrator stated there was no full-time RN designated to be the DNS working full-time at the facility and involved in resident care. The Administrator admitted knowledge of the need for a full-time DNS. The personnel file of the Interim DNS did not include a signed form of her job description. During an interview on 12/01/23 at 11:00 AM, the Interim DNS stated she was not in the facility on a full-time basis and had other job duties on the facility campus. The Interim DNS also stated she was not involved in resident care planning and in the provision of nursing services in the facility on a daily basis.

Based on staff interview and document review, it was determined the facility failed to report accurate Payroll Based Journal (PBJ) information for the facility as required for a census of 44 residents. Findings include: The facility's PBJ report, for 7/1/23 through 9/30/23, documented a full time RN functioned as the DNS in the facility. During an interview on 11/29/23 at 10:10 AM, the Administrator confirmed the facility did not employ a full time RN to serve as the DNS, as reported in the PBJ report. During an interview on 11/30/23 at 10:55 AM, the facility's Corporate Human Resources Representative confirmed the facility replaced the previous DNS with the Interim DNS on 5/8/23. Additionally, she confirmed the Interim DNS's employee file did not include an accepted and signed DNS job description defining job duties. During an interview on 12/1/23 at 11:00 AM, the Interim DNS stated she was not in the facility on a full-time basis and had other job duties on the facility campus, specifically in the assisted living facility, which was in another building. The Interim DNS also stated she was not involved in resident care planning and in the provision of nursing services in the facility on a daily basis.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure employees were trained on abuse. This was true for 43 of 79 employees whose records were reviewed for abuse training. This failure had the potential to place all residents in the facility for unidentified or continued abuse if an employee was unable to identify and report abuse. Findings include: The facility's Reducing the Threat of Abuse and Neglect policy, revised December 2022, stated the facility would implement and maintain an effective training program on abuse prohibition. This policy was not followed. During a review of employee abuse training, it was identified 43 of 79 employees did not complete training for abuse and neglect. On 12/1/23 at 10:32 AM, the Resident Care Coordinator stated 43 of 79 employees did not complete training for abuse and neglect.

Based on review of the State Agency's Long Term Care Reporting Portal, record review, incident reports, and staff interview, it was determined the facility failed to ensure allegations of resident abuse were reported to the State Survey Agency within 2 to 24 hours. This affected 2 of 5 residents (#7 and #8) who were reviewed for abuse, and for additional unidentified residents referenced in 2 incident reports. This failure created the potential for residents to be subjected to ongoing abuse without detection and protective measures implemented by the facility. Findings include: The facility's policy, Reducing the Threat of Abuse and Neglect, revised 12/21/23, stated allegations of abuse were to be reported to the State Survey Agency Long Term Care reporting Portal within 2-24 hours of the event, and report the results of an investigation within 5 working days from the date of the incident. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including dementia with agitation, depression, and conduct disorder. An admission MDS assessment, dated 10/19/23, documented Resident #4's cognitive skills for daily decision making were severely impaired. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease and dementia with psychotic disturbances. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease and dementia. Resident #10 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including bipolar disorder and dementia. 1. A facility incident report, dated 1/31/24, documented Resident #4 was opening and slamming another resident's door, punching into the air, walls, and other residents' doors. When the staff attempted to redirect him, he began yelling out at no one then aimed attention toward sleeping resident in recliner. he [sic] attempted to swing at that resident. Other residents were removed from common area to accommodate this resident. A Staff Statement, dated 1/31/24, documented, during the incident, Resident #4 entered the room shared by Resident #7 and Resident #8 and slammed the door closed. When staff members tried to open the door, he attempted to hit them and punched the door 4-5 times, resulting in injuries to his hands and small cuts on his forearm. Resident #4 then came further out of the room in an attempt to hit the staff members and the staff were able to block him from reentering the room. The Statement documented Resident #4 became a danger to himself, the women in the room, and us [staff]. Review of the State Agency's Long Term Care Reporting Portal did not include a report of the above incident. 2. Resident #4's medical record included a Behavior Note, dated 2/2/24. The note documented Resident #4 was opening and slamming another resident's door, punching other residents' doors, yelling, and punching walls and into the air. He then attempted to swing at a sleeping resident in the common area. The staff removed other residents from the common area. A facility incident report, dated 2/2/24, documented Resident #4 was yelling in the direction of other residents and staff intervened when he tried to swing. Review of the State Agency's Long Term Care Reporting Portal did not include a report of the above incident. On 2/7/24 at 2:00 PM, the Administrator and the DON were interviewed together. When asked if the 1/31/24 and 2/2/24 incidents were investigated for potential abuse, they stated they were not. When asked if the incidents were reported to the State Agency Portal, the Administrator stated they were not since he thought that abuse was to be reported only when physical contact was made.

Based on review of the State Agency's Long Term Care Reporting Portal, record review, incident reports, and staff interview, it was determined the facility failed to ensure allegations of resident abuse were reported to the State Survey Agency within 2 to 24 hours. This affected 2 of 5 residents (#7 and #8) who were reviewed for abuse, and for additional unidentified residents referenced in 2 incident reports. This failure created the potential for residents to be subjected to ongoing abuse without detection and protective measures implemented by the facility. Findings include: The facility's policy, Reducing the Threat of Abuse and Neglect, revised 12/21/23, stated allegations of abuse were to be reported to the State Survey Agency Long Term Care reporting Portal within 2-24 hours of the event, and report the results of an investigation within 5 working days from the date of the incident. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including dementia with agitation, depression, and conduct disorder. An admission MDS assessment, dated 10/19/23, documented Resident #4's cognitive skills for daily decision making were severely impaired. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease and dementia with psychotic disturbances. Resident #8 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease and dementia. Resident #10 was initially admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including bipolar disorder and dementia. 1. A facility incident report, dated 1/31/24, documented Resident #4 was opening and slamming another resident's door, punching into the air, walls, and other residents' doors. When the staff attempted to redirect him, he began yelling out at no one then aimed attention toward sleeping resident in recliner. he [sic] attempted to swing at that resident. Other residents were removed from common area to accommodate this resident. A Staff Statement, dated 1/31/24, documented, during the incident, Resident #4 entered the room shared by Resident #7 and Resident #8 and slammed the door closed. When staff members tried to open the door, he attempted to hit them and punched the door 4-5 times, resulting in injuries to his hands and small cuts on his forearm. Resident #4 then came further out of the room in an attempt to hit the staff members and the staff were able to block him from reentering the room. The Statement documented Resident #4 became a danger to himself, the women in the room, and us [staff]. Review of the State Agency's Long Term Care Reporting Portal did not include a report of the above incident. 2. Resident #4's medical record included a Behavior Note, dated 2/2/24. The note documented Resident #4 was opening and slamming another resident's door, punching other residents' doors, yelling, and punching walls and into the air. He then attempted to swing at a sleeping resident in the common area. The staff removed other residents from the common area. A facility incident report, dated 2/2/24, documented Resident #4 was yelling in the direction of other residents and staff intervened when he tried to swing. Review of the State Agency's Long Term Care Reporting Portal did not include a report of the above incident. On 2/7/24 at 2:00 PM, the Administrator and the DON were interviewed together. When asked if the 1/31/24 and 2/2/24 incidents were investigated for potential abuse, they stated they were not. When asked if the incidents were reported to the State Agency Portal, the Administrator stated they were not since he thought that abuse was to be reported only when physical contact was made.

Based on record review and staff interview, it was determined the facility failed to ensure a resident's representative and physician were immediately notified when the resident had a significant change in condition. This was true for 1 of 1 resident (Resident #352) reviewed for notification of change in condition. This deficient practice placed Resident #352 at risk for lack of advocacy and support from their representative, and deterioration of her health status. Findings include: The facility's Change in a Resident's Condition or Status policy, revised February 2021, stated the facility will promptly notify the resident, his or her attending physician and the resident representative of changes in the resident's medical/mental condition. This policy was not followed. Resident #352 was readmitted to the facility on [DATE], with multiple diagnoses including dementia with behavioral disturbances. A nurse's note, dated 1/15/22 at 4:32 AM, documented Resident #352 was repeatedly yelling help me and having visual hallucinations. The note also documented Resident #352 had a fever of 104.1 degrees (normal temperature is 98.6 - 100.4 degrees) Resident #352's record did not include documentation Resident #352's physician and representative were notified of her change in condition. A nurse's note, dated 1/16/22 at 2:17 AM, documented Resident #352 was yelling and calling out mother of God help. The nurse's note documented Resident #352's oxygen saturation (percentage of oxygen in the blood) was 88% (normal is 95% - 100%). Resident #352's record did not include documentation Resident #352's physician and representative were notified of her change in condition. On 11/30/23 at 2:38 PM, the Administrator stated the facility did not have documentation of notification for change in condition for Resident #352.

Based on record review, policy review, and resident staff interview, it was determined the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASRR) was completed when the resident had a clinical diagnosis of Post-Traumatic Stress Disorder (PTSD). This was true for 1 of 1 resident (Resident #16) whose PASRR record was reviewed. This deficient practice had the potential to cause harm if residents' specialized services for mental health needs were not provided due to a lack of updated screening. Findings include: The Medicaid (government entity that provides health coverage to Americans) long term care PASRR website accessed on 12/14/23, documented the following: PASRR is a federal requirement for Medicaid-certified nursing facilities to help ensure that individuals are not inappropriately placed in nursing homes for long term care. The PASRR procedures include: - Evaluate all applicants for serious mental illness (SMI) and intellectual disability (ID). - Offer all applicants the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings). - Provide all applicants with the services they need in those settings. The PASRR procedure further documented the nursing facilities would conduct a Level I screen, a preliminary assessment to determine whether a resident might have SMI or ID when admitted to the facility. Those individuals who tested positive at Level I would then be evaluated in depth, called Level II PASRR. The PASRR screening results were to determine needs and appropriate health care settings and a set of recommendations for services to inform the individual's plan of care. The facility's policy titled, Admission Criteria, revised 3/2019, documented all new admissions were screened for mental disorders and other related disorders (RD). The policy further documented all potential admissions would have a Level I PASRR completed to determine if the resident met the criteria. If the Level I screen documented that the individual may have met the criteria for RD, then they would be referred to the state PASRR representative for the Level II (evaluation and determination) screening process. The policy further documented the admitting nurse should notify the social services department when a resident was identified with a possible RD. The policy documented the social worker was responsible for the referral to the state authority. After the Level II evaluation was completed, the state PASRR representative would determine if a physical or mental condition was present and what specialized services the resident needed. The determination would be provided to the facility. The interdisciplinary team would determine if the facility could meet the needs of the resident. These requirements and policy were not followed. Resident #16 was admitted on [DATE], with multiple diagnoses including PTSD (a mental health condition that is triggered by a terrifying event). An admission MDS assessment, dated 5/13/22, documented Resident #16 was cognitively intact. The assessment documented his onset for the diagnosis of PTSD was 5/11/22. Resident #16's Care Plan, revised 4/27/23, documented Resident #16 had depression related to PTSD and medical issues. Resident #16's goal was to exhibit indicators of depression, anxiety, or sad mood less than daily. The interventions included administration of medications, as ordered, and monitor and document any risk for self-harm or suicide plan. Resident #16's Idaho Level I PASRR Screen, dated 5/9/23, documented PTSD had not been checked for the question, Does the resident have any of the following Major Mental Illness, which included PTSD. The Level I PASRR was signed by the physician and the resident. There was no indication a Level II PASRR was completed. Resident #6's history and physical, dated 5/9/22, did not include his PTSD diagnosis. During an interview on 11/28/23 at 3:05 PM, Resident #16 stated he had PTSD from his military service. Resident #16 stated he was shot several times while in the military. Resident #16 further stated he had a Veterans' counselor that he could talk to. During an interview on 11/30/23 at 9:29 AM, LPN #5 and LPN #6 stated they were not aware of the diagnosis of PTSD. During an interview on 11/30/23 at 10:40 AM, LPN #6 stated a PASRR was a preadmission screening tool for mental disorders that may require additional care. LPN #6 further stated the screening was based on the history and physical given to the facility. The Level I PASRR was completed by her with the information provided by the history and physical, which did not include a diagnosis of PTSD. LPN #6 stated she was not sure when the diagnosis was added but a new Level I PASRR should have been initiated and sent to the health and welfare agency to be screened for a Level II PASRR.

Based on observation, record review, policy review and resident and staff interview, it was determined the facility failed to ensure residents' care plans were revised to reflect current needs and interventions. This was true for 1 of 23 residents (Resident # 26) whose care plans were reviewed. This deficiency placed residents at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents ' needs changed. Findings include: The facility's Care Plan policy, revised March 2022, documented the comprehensive, person-centered care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility's Change in a Resident's Condition or Status policy, revised February 2021, documented the interdisciplinary team reviewed and updateded the care plan when there was a significant change in the resident's condition, when the desired outcome was not met, when the resident was readmitted to the facility from a hospital stay, and at least quarterly, in conjunction with the required quarterly MDS assessment. These policies were not followed. Resident # 26 was admitted on [DATE] and readmitted on [DATE], with multiple diagnoses including Type 2 diabetes with kidney disease, and dependence on renal dialysis. Resident # 26's care plan, dated 9/20/21, documented daily weights were to be measured at the same time and same scale each day. The care plan directed staff to notify Resident 26's Nephrologist if she had weight gain greater than or equal to 5 pounds in 3 days. The Weights and Vital Signs Summary report for November 2023, documented a weight for Resident #26 on 11/2/23 at 2:00 PM and 11/6/23 at 8:11 AM. The report did not document daily weights each day at the same time as directed by the care plan. On 11/29/23 at 11:49 AM, LPN # 1 stated the order for daily weights for Resident #26 was discontinued and the care plan should have been revised at that time.

Based on resident and staff interview, record review, and facility policy review, it was determined the facility failed to assess, monitor, and identify potential triggers for 1 of 1 resident (Resident #16) reviewed for trauma-informed care. This failure created the potential for . Findings include: The facility's policy Trauma-Informed and Culturally Competent Care Level III, revised 8/2022, stated the purpose of the policy was to guide staff in providing care that was culturally competent and trauma-informed in accordance with professional standards of practice, and to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. The policy further defined Trauma results from an event, series of events, or set of circumstances that was experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. The policy defined Trauma-informed care as an approach to delivering care that involved understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognized the widespread impact and signs and symptoms of trauma in residents, and incorporated knowledge about trauma into care plans, policies, procedures, and practices to avoid re-traumatization. The policy defined Trigger as a psychological stimulus that prompted recalled previous traumatic event, even if the stimulus itself was not traumatic or frightening. The policy stated all staff were provided with training in trauma and trauma-informed care. The policy stated nursing staff were to be trained in trauma screening and assessments, including evaluating the presence of symptoms with the trauma and the identification of triggers. The care planning section of the policy stated staff were to identify and decrease exposure to triggers that may re-traumatize the resident. The policy stated an individualized care plan was to be developed. The initial screening was to be utilized to identify the need for further assessment and care. Resident #16 was admitted on [DATE], with multiple diagnoses including Post-Traumatic Stres Disorder (PTSD - a mental health condition that is triggered by a terrifying event), paraplegia (paralysis), and major depressive disorder. Resident #16's quarterly MDS assessment, dated 10/10/23, documented he had feelings of being down, depressed, bad about himself, let himself down, and that he might be better off dead nearly every day. Further review of the MDS documented Resident #16 would refuse care frequently. Resident #16's care plan, with a revised date of 4/27/23, documented a problem with depression related to PTSD and medical issues. Resident #16's goal was to exhibit indicators of depression, anxiety, or sad mood less than daily. The interventions included administration of medications as ordered, and monitor and document any risk for self-harm or suicide plan. Resident #16's care plan, revised 4/27/23, further documented his use of antidepressant medications. The goal was for Resident #16 to be free of discomfort and adverse reactions. The interventions included monitoring for adverse reactions and allowing Resident #16 to call the Veterans Administration (VA) counselor when he felt he needed. During an interview on 11/28/23 at 3:05 PM, Resident #16 stated he was diagnosed with PTSD from when he was in the military in Afghanistan. Resident #16 stated he had been shot several times. Resident #16 stated his wife wanted a divorce after he returned home, and he tried to commit suicide. During an interview on 12/1/23 at 8:45 AM, the Complex Care Unit (CCU) Coordinator stated she conducted the social services aspect for residents. The CCU Coordinator further stated Resident #16 had PTSD and had tried to commit suicide in the past when he lived at his home. The CCU Coordinator stated she did not know what Resident #16's triggers were from PTSD. She further stated she had spoken to Resident #16 on numerous occasions, but they had not discussed triggering events for PTSD. She stated she had encouraged Resident #16 to get outside counseling, but he preferred to talk to the VA counselors and for God to help him through. She stated behavior monitoring was not done for Resident #16's PTSD triggers. The CCU Coordinator stated she did the initial social services documentation, but the trauma informed care was done by nursing. She stated there were no interventions in the care plan for triggers from PTSD and there should have been. During an interview on 12/1/23 at 9:29 AM, LPN #5 stated she and LPN #6 completed the resident assessments for Resident #16. LPN #5 stated they were not aware of Resident #16's PTSD and did not assess for any triggers. LPN #5 further stated Resident #16 should have been assessed for triggers. During an interview on 12/1/23 at 9:34 AM, the MDS Coordinator stated Resident #16 was depressed and self-isolating. She stated she had talked to him on admission, but he did not tell her he had PTSD. She stated a physician's note and a quarterly summary alerted her to the PTSD diagnosis. The MDS Coordinator stated she did not do the trauma informed care assessments and care plan, LPN #5 or CCU Coordinator did. She reviewed the care plan and stated there was a problem for depression that was added on 4/19/23 and PTSD was added as a diagnosis, however no interventions or triggers were initiated. She stated triggers for Resident #16's PTSD should have been addressed and care planned. She stated she did not know what Resident #16's triggers were. The MDS Coordinator stated the necessity of identifying triggers were to ensure Resident #16 did not have suicidal ideation and he did not put himself in a triggered situation. During an interview on 12/1/23 at 9:59 AM, CNA #3 stated she had training on trauma informed care. CNA #3 stated the CNA book and the care plan was where potential triggers for residents were documented. CNA #3 stated she was not aware of any residents who had identified triggers related to PTSD.

Based on policy review, observation, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when providing wound care. This was true for 1 of 1 resident (Resident #2) observed during wound care. This failure put Resident #2 at risk for infection due to cross contamination and potential exposure to bacteria and other pathogens. Findings include: The facility's Dressings, Dry/Clean policy, revised September 2013, documented after a soiled dressing was removed, to pull the soiled glove used over the dressing and discard. If gauze was used to clean the wound, use clean gauze for each cleansing stroke. The policy stated staff were to initial the clean dressing and label it with the date and time the dressing was changed. This policy was not followed. Resident #2 was admitted [DATE], with multiple diagnoses including an open wound of the abdominal wall. On 11/28/23 at 12:09 PM, LPN #1 was observed providing wound care to Resident #2. LPN #1 donned gloves, positioned Resident #2 in bed, adjusted her blankets, and set up wound care supplies on the bedside table. LPN did not perform hand hygiene, change her gloves or cleanse the bedside table before setting up the wound supplies. She then removed Resident #2's soiled wound dressing without performing hand hygiene and changing her gloves. She changed one glove after removing the soiled dressing without performing hand hygiene. She cleansed Resident #2's abdominal wound with one gauze pad to clean multiple areas of the wound. LPN #1 then applied a clean dressing to Resident #2's abdominal wound without performing hand hygiene and changing her gloves. LPN #1 did not label the dressing with the date, time, or her initials. On 11/28/23 at 12:35 PM, LPN # 1 stated she should have cleansed Resident #2's wound with multiple gauze pads. She stated she should have changed her gloves before removing Resident #2's soiled dressing and after completing wound care. LPN # 1 stated she should have completed hand hygiene each time she removed her gloves. She stated she was not aware of the need to date, time, and initial dressings.

Based on observation, policy review, nationally recognized standards of practice, and staff interview, it was determined the facility failed to ensure infection control prevention practices were consistently implemented and maintained to provide a safe and sanitary environment. This failure created the potential for negative outcomes by exposing residents to the risk of infection and cross-contamination including COVID-19. Findings include: 1. Staff working in the facility did not consistently don (put on) the correct PPE in the COVID-19 positive unit, in the unit that housed residents with signs and symptoms of COVID-19, and in the unit that housed residents with possible exposure to COVID-19. a. The facility's guidance for Infection Prevention and Control for COVID-19, revised 6/5/20, stated staff should wear a gown, gloves, eye protection, and a respirator mask for the care of all residents when there was a facility outbreak. This guidance was not followed. i. On 8/25/20 at 1:45 PM, the outside doors to the facility's COVID-19 positive unit had two signs on the door. One sign directed staff to wear full PPE, including a respirator mask, face shield or goggles, a gown, and gloves. A second sign stated, Staff Respirators and face shield/goggles are to be warn (sic) at all times except while eating. Gowns and gloves are to be worn when entering patient rooms. CNA #2 admitted the surveyor into the COVID-19 unit through the locked doors and followed the surveyor into the unit. All three resident rooms' doors were closed and there were no residents or other staff in the common area of the unit. CNA #2 had on a respirator mask, goggles, and scrubs. She did not wear a gown or gloves. At 1:53 PM, CNA #2 then performed hand hygiene outside of Resident #9's room and donned a gown and gloves and went into Resident #9's room. At 1:55 PM, CNA #2 doffed (took off) her gown and gloves and performed hand hygiene just inside Resident #9's room. She then picked up Resident #9's meal tray with her bare hands, left the room and placed the tray on a cart in the common area of the COVID-19 unit and performed hand hygiene. CNA #2 did not don a gown or gloves. She then took a large plastic covering and placed it over the tray cart and wheeled it to the plastic barrier that separated the COVID-19 positive unit from the rest of the building. She then unzipped the barrier, moved the cart out of the unit and zipped the barrier closed, and performed hand hygiene. At 2:03 PM, CNA #2 was seated at the nurses' station charting on an electronic device with bare hands and was not wearing a gown. On 8/25/20 at 2:05 PM, CNA #2 said she wore a gown and gloves when in residents' rooms or when with a resident who tested positive for COVID-19. She said she thought she only had to wear a gown and gloves in the COVID-19 unit common area when residents were also in the common area. On 8/25/20 at 2:55 PM, the DON said she expected staff to wear full PPE, including a gown and gloves, while in the COVID-19 positive unit. She said the sign on the outside of the COVID-19 unit door was intended to remind staff not to wear a gown and gloves in the COVID-19 unit staff breakroom. ii. On 8/25/20 from 9:53 AM to 11:35 AM, the following was observed on the facility's unit with residents who were potentially exposed to COVID-19. * At 11:30 AM, LPN #1 delivered and set up Resident #6's meal on her tray table in her room. LPN #1 did not don a gown prior to entering the room. * At 11:34 AM, LPN #1 delivered and set up Resident #7's meal tray on his tray table in his room. LPN #1 did not don a gown prior to entering the room. * At 11:35 AM, CNA #5 delivered and set up Resident #9's meal on her tray table in her room. CNA #5 did not don a gown prior to entering the room. On 8/25/20 at 11:40 AM and 2:55 PM, the DON said staff were to wear gowns when delivering meal trays. b. The facility's Transmission-Based Precautions policy, revised 10/2018, stated personal eyeglasses should not be considered adequate protective eye protection This policy was not followed. i. On 8/25/20 at 1:56 PM, CNA #1 was observed in the COVID/Pink hall which included rooms #216 through #219. CNA #1 said the hallway had 3 residents who exhibited symptoms of COVID-19, and she thought they were on droplet precautions. CNA #1 said the 3 residents in the COVID/Pink hall had negative test results for COVID-19, and they were under observation for 7 more days. Two male residents were sitting in the hallway, and CNA #1 spoke to them. CNA #1 was wearing PPE which included a gown, gloves, a respirator mask, and she was wearing personal eyeglasses. CNA #1 said staff who worked in that hallway should wear a gown, gloves, and facemask. CNA #1 said staff were wearing a face shield when working in that area up until 2 days ago, but she was told it was no longer necessary to wear a face shield. On 8/25/20 at 3:00 PM, the DON said staff should wear eye protection when working in the COVID/Pink hall where residents who were suspected of having COVID-19 resided. ii. On 8/25/20 at 9:40 AM, the DON said room [ROOM NUMBER] through room [ROOM NUMBER] had residents who were potentially exposed to individuals who tested positive for COVID-19. On 8/25/20 from 9:53 to 11:35 AM, the following was observed on the unit: * At 9:53 AM, CNA #4 wheeled Resident #1 from the hallway into her room. CNA #4 had on a respirator mask and personal eyeglasses. She put on a gown and gloves and assisted Resident #1 into her room and closed the dor. CNA #4 did not put on eye protection. * At 9:57 AM and 10:05 AM, CNA #3 went into Resident #2's room. CNA #3 wore personal eyeglasses. She was not wearing a face shield or goggles for eye protection. On 8/25/20 at 10:30 AM, CNA #3 said she did not wear eye protection when going into residents' rooms on the unit. She said she was told her personal eyeglasses offered enough protection. On 8/25/20 at 11:22 AM, CNA #4 said she did not wear eye protection when going into residents' rooms on the unit. She said she was told her personal eyeglasses offered enough protection. On 8/25/20 at 11:40 AM and 2:55 PM, the DON said personal eyeglasses were not appropriate eye protection and she expected staff to wear goggles or face shields when on the potentially exposed unit. 2. The facility's guidance for Infection Prevention and Control for COVID-19, revised 6/5/20, stated signs indicating appropriate precautions were to be placed outside of resident rooms. The facility's policy for Categories of Transmission-Based Precautions, revised 10/2018, stated: * When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. * The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instruction to see a nurse before entering the room. This guidance was not followed. On 8/25/20 at 9:40 AM, the DON said rooms #220 through #239 were occupied by residents who were potentially exposed to individuals who tested positive for COVID-19. On 8/25/20 at 9:45 AM, the unit had a door which was closed with a sign on it directing staff how to don and doff PPE. There was no signage on the door instructing staff when and what PPE to wear while on the unit. The resident room doors #220 to #239 did not have signage outside the rooms instructing staff when and what PPE to wear. On 8/25/20 at 11:00 AM, LPN #1 said there were no precaution signs on the unit doors or on the residents' room doors. LPN #1 said the residents on the unit were probably on contact precautions but said she was not sure. On 8/25/20 at 11:22 AM, CNA #4 said she did not know what precautions staff were to take, except to wear a gown when providing direct care for the residents, like using the toilet or changing incontinent briefs. On 8/24/20 at 11:40 AM and 2:55 PM, the DON said staff should be following COVID precautions for the potentially exposed unit. She said that meant droplet precautions with eye protection and a respirator mask. The DON said there was no signage and there should be a precaution sign for the unit to inform staff what PPE to wear. 3. The facility's policy for Handwashing/Hand Hygiene, revised 8/2019, documented hand hygiene should be performed using alcohol-based hand rub or soap and water after contact with objects in the immediate vicinity of the resident, after removing gloves, and before and after entering isolation settings. A document provided by the facility, undated, had instructions for how to safely remove PPE. The document stated the following: * The outside of goggles or face shield are contaminated. If hands become contaminated, immediately wash your hands or use alcohol-based hand sanitizer. * The front of the mask/respirator is contaminated. If hands become contaminated, immediately wash your hands or use alcohol-based hand sanitizer. This policy and guidance were not followed. Examples include: a. On 8/25/20 from 9:57 AM to 10:22 AM and 10:32 to 10:38 AM, Housekeeper #1 was observed cleaning 3 resident rooms in the facility's unit with residents who were potentially exposed to COVID-19. At 9:57 AM, Housekeeper #1 was in Resident #2's room and was wearing a gown, gloves, goggles, and a respirator mask. At 9:59 am, she came out of the room with a used rag she had just used to clean the toilet. Housekeeper #1 then disposed of the rag and doffed her gloves. She did not perform hand hygiene. Housekeeper #1 then donned new gloves and took a new wet rag and wiped surfaces in the room. Housekeeper #1 then disposed of the rag and doffed her gloves. She did not perform hand hygiene. Housekeeper #1 then donned new gloves and swept and mopped the room floor. At 10:08 AM, Housekeeper #1 doffed her gloves and performed hand hygiene. She then dropped her goggles on the floor and picked them up and placed them on her cart. She then put on a new pair of goggles adjusted her hair, moved her cart to Resident #3 and Resident #4s' room, picked up a wet floor sign and placed it outside of Residents #3 and Resident #4s' room. Housekeeper #1 then donned new gloves without performing hand hygiene before putting on the new gloves. At 10:11 AM, Housekeeper #1 removed Residents #3 and Resident #4s' garbage from the garbage cans and placed new plastic liners in the garbage cans. She then took a new wet rag and wiped down the paper towel dispenser, wheelchair and walker handles, the window seal, and 2 transfer poles. At 10:22 AM, she doffed her gloves and her gown and performed hand hygiene. At 10:32 AM, Housekeeper #1 pushed her cart with bare hands to Resident #5's room. She adjusted her goggles and her facemask with her hands. She did not perform hand hygiene. She then donned new gloves. Housekeeper #1 then took a new wet rag and wiped down surfaces in Resident #5's room. She then disposed of the rag and doffed her gloves. She did not perform hand hygiene. Housekeeper #1 then donned new gloves. She took a new wet rag and wiped the counter and sink. On 8/25/20 at 10:40 AM, Housekeeper #1 said she did not perform hand hygiene after removing her gloves until she was finished cleaning each room. She said she did not know she was not supposed to touch her mask. b. On 8/25/20 at 1:56 PM, CNA #1 was observed in the hallway that included rooms #216 through #219. CNA #1 said the hallway had 3 residents who exhibited symptoms of COVID-19, and she thought they were on droplet precautions. CNA #1 said the 3 residents had negative test results for COVID-19, and they were under observation for 7 more days. CNA #1 was wearing PPE which included a gown, gloves, and respirator mask. CNA #1 removed her gloves and gown and hung the gown on the door of the employee breakroom. CNA #1 then exited the hall to go outside. She did not perform hand hygiene after she removed her PPE. On 8/25/20 at 2:15 PM, CNA #1 said she forgot to wash her hands after she removed her PPE. On 8/25/20 at 3:00 PM, the DON said staff should perform hand hygiene after removing PPE and after touching their masks and goggles.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were implemented and maintained to provide a safe and sanitary environment. This failure created the potential for negative outcomes by exposing residents to the risk of infection and cross-contamination including COVID-19. Findings include: 1. The facility's policy, Personal Protective Equipment - Contingency and Crisis Use of Isolation Gowns (COVID-19 Outbreak), dated April 2020, stated, Extend use of isolation gowns so that same gown is worn by the same HCP when interacting with more than one resident known to be infected with the same infectious disease . This policy was not followed. On 7/14/20 at 9:32 AM, Resident #3 had 3 yellow fabric gowns hanging from individual hooks inside the room on the door. A green sign was posted on the door, which indicated Droplet Precautions were in place. On 7/14/20 at 10:10 AM, CNA #4 entered Resident #3's room and grabbed a yellow cloth gown from the inside of Resident #3's door which was hanging from the first hook on the left. When CNA #4 finished with Resident #3's cares, she returned the yellow gown to the hook where she obtained it. On 7/14/20 at 10:30 AM, CNA #6 exited Resident #3's room. Two gowns were hanging on the inside of the door and CNA #6 was wearing the same gown that CNA #4 used previously. CNA #6 said she was using the gown that was hanging on the first hook inside on the left of the door, and she was not aware the gown was previously worn by another person. CNA #6 said the gown was supposed to be labeled with a piece of tape, and staff were to use their own gown during their shift. On 7/14/20 at 1:35 PM, the DNS said the isolation gowns were reusable, and when staff removed the gown they should fold it from the outside in and hang it up on the door. The DNS said only one person should wear the gown, and it was not intended for multiple people to wear the same gown. The DNS said each employee should choose where to hang their gown on the door, the gown should be sent to the laundry at the end of their shift, and each gown was good for 100 washes. 2. The facility's Handwashing/Hand Hygiene policy, dated August 2019, stated all personnel should follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors, including before and after direct contact with residents, and after contact with objects in the immediate vicinity of the resident. The facility's Standard Precautions policy, dated July 2020, stated standard precautions applied to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. The policy stated: * Hand hygiene referred to handwashing with soap or the use of alcohol-based hand rub (ABHR), which did not require access to water. * Hand hygiene was performed with ABHR or soap and water before and after contact with the resident, and after contact with items in the resident's room. On 7/14/20 at 11:15 AM, CNA #1 was observed holding a soiled linen bag in her left hand while assisting Resident #1 to her seat in the East Wing common area. CNA #1 had her right hand on Resident #1's back and belt. While walking to the seat, CNA #1 passed the soiled linen bag to CNA #2 who took it into the soiled linen room. After seating Resident #1, CNA #1 rolled two side tables in front of two chairs in preparation for lunch service by grasping the tops of the tables. CNA #1 did not perform hand hygiene prior to touching the tables and after holding Resident #1 by her clothing. CNA #1 then assisted CNA #3 by grasping Resident #2 under her left arm and sliding Resident #2 up in her reclining wheelchair. CNA #1 then performed hand hygiene. On 7/14/20 at 11:50 AM, CNA #1 said after assisting a resident with personal cares, the CNAs took the soiled linen bag to the soiled linen room and washed their hands with soap and water thoroughly. CNA #1 stated she should have performed hand hygiene prior to touching residents and dining tables. On 7/14/20 at 1:30 PM, the DNS said the protocol for handling soiled linen after assisting a resident with personal cares required a CNA to place the soiled linens in a bag and take it to the soiled linen room, and then perform hand hygiene. The DNS said it was not acceptable for staff to touch residents or items after handling a soiled linen bag. 3. The facility's policy for Personal Protective Equipment-Using Gowns, revised September 2010, stated staff were to untie the back of the gown when removing it. A document provided from the facility, titled How to Safely Remove PPE, undated, directed staff to unfasten the gown ties when removing the gown, and to be careful to avoid contact with the sleeves of the gown. This policy and guidance was not followed. On 7/14/20 at 10:10 AM, CNA #4 was in the hall assisting Resident #3 who was in her wheelchair. Resident #3 had a sign on her door indicating she was on Droplet Precautions, which requires face masks and gloves were worn when entering the room, and a gown and goggles should be worn if there was risk of spraying respiratory secretions. CNA #4 grabbed a yellow cloth gown from the inside of Resident #3's door which was hanging from the first hook on the left. The gown was tied at the top, and CNA #4 put it on by pulling it over her head. On 7/14/20 at 10:13 AM, CNA #4 opened the door to Resident #3's room and removed the gown by pulling it over her head. She returned the gown to the hook, performed hand hygiene, and exited the room. On 7/15/20 at 8:45 AM, CNA #4 said she did not untie the gown. CNA #4 said the reusable gown had the ties fastened so it could be hung up. CNA #4 said staff were not trained to leave the gown tied and pull it over their head.

Based on staff interview, policy review, and record review, it was determined the facility failed to ensure adequate supervision of residents to prevent falls. This was true for 1 of 1 resident (Resident #163) who were reviewed for falls. Resident #163 was harmed when staff failed to provide adequate supervision while the resident was in her room when she fell and sustained a left eyebrow laceration which required suturing. Findings include: Resident #163 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple [DIAGNOSES REDACTED]. Resident #163's hospital record, dated 2/11/18, documented she was admitted to the hospital due to acute mental status changes, back pain, and an unwitnessed fall in her home. The hospital record also documented Resident #163 had numerous falls mostly non-injury over the last 2 years. Resident #163's quarterly MDS assessment, dated 5/22/18, documented she had severe cognitive impairment, required 1 assist with activities of daily living, and set-up for eating. A Fall Risk Evaluation, dated 3/10/18, 4/4/18, and 5/20/18, documented Resident #163 was at high risk for falls. A Potential for Falls/Fall Prevention care plan, dated 3/20/18, documented Resident #163 had impaired cognition, incontinent of bowel and bladder, and had history of falls. Interventions included in the care plan documented staff were to provide well fitting, non skid footwear, safety checks every 15-30 minutes, keep immediate environment free of obstacles, place call light within reach, fall risk assessment quarterly and when necessary for changes when clinically indicated, and do not leave the resident in room in wheel chair unattended. Resident #163's medication included the following: *[MEDICATION NAME] 10 mg daily for depression. *[MEDICATION NAME] 15 mg at bedtime for weight loss. An Incident and Accident (I&A) report, dated 3/3/18 at 8:00 AM, documented Resident #163 experienced an unwitnessed fall in her bathroom with no injury. She was found sitting on her buttocks with her pants off and her incontinent brief to her knees. An I&A report, dated 3/15/18 at 10:05 AM, documented Resident #163 experienced an unwitnessed fall in her room with no injury. She was found sitting on the floor. An I&A report, dated 4/4/18 at 2:15 PM, documented Resident #163 experienced an unwitnessed fall in her room with no injury. She was found sitting on the floor. A CNA statement documented she was not aware Resident #163 was brought to her room after lunch and was left unattended in her room. An I&A report, dated 4/26/18 at 5:50 PM, documented Resident #163 was just brought back to her room after dinner, when she self-transferred from her wheelchair to her chair and slid to the floor. A Nursing Note, dated 5/7/18, documented Resident #163 was walking on her own in the hallways. A physician's orders [REDACTED].#163's [MEDICATION NAME] while she was on [MEDICATION NAME]. A Nursing Note, dated 5/9/18, documented Resident #163 continued to be impulsive and she was found in the bathroom on her own. A Nursing Note, dated 5/12/18, documented Resident #163 was very worried about her husband's condition. A physician's orders [REDACTED].#163 to received Zanax 0.5 mg every 8 hours as needed for anxiety. A Nursing Note, dated 5/17/18 at 4:30 PM, documented Resident #163's representative requested the Zanax 0.5 mg to be given at a half the dose. A physician's orders [REDACTED].#163's Zanax was decreased to 0.25 mg every 8 hours as needed for anxiety. A Nursing Note, dated 5/17/18, documented Resident #163 had no adverse effect with the Zanax. She did not have signs and symptoms of anxiety/depression with the passing of her husband. An I&A report, dated 5/18/18 at 5:00 AM, documented Resident #163 experienced an unwitnessed fall in her room. She was found on the floor and observed to have sustained a 4-5 centimeter laceration above her left eyebrow, 2 bruises on the left side of her neck, and a bruise on her left knee which was about 4 cm by 4 cm in size. A 2.5.cm by 2.5 cm abrasion was also noted in the middle of the bruise on her left knee. Resident #163 was sent to the hospital due to her laceration above her left eyebrow. A hospital report, dated 5/18/18, documented Resident #163 had dementia and had increased stress recently since her husband passed away. A 3 centimeter laceration on her left eyebrow was sutured. On 1/18/19 at 3:26 PM, the DNS said the facility stopped residents' safety checks every 15 to 30 minutes. The DNS said Resident #163 was placed on a Falling Star Program which included 30 minutes checks of the resident. The DNS stated all staff members completed the 30 minute checks but it might not have been documented. The DNS said Resident #163 should not have been left in her room unattended when she was up in her wheelchair. The DNS stated if Resident #163 was in her room, in her wheelchair, she did not know who watched her because the staff working would assist with needs like this. The DNS stated she would look for what interventions were in place for Resident #163 when Resident #163 started to self transfer and attempted to take herself to the bathroom. The DNS stated the incident report where Resident #163 sustained a laceration from a fall documented Resident #163 was seen in her bed by nursing approximately 30-1 hour before. The DNS stated for high fall risk residents the facility should have implemented completing a bowel and bladder eval, when Resident #163 was found in the bathroom following falls, a physical therapy eval, her room moved closer to the nurses' station, and Resident #163 in line of sight in the common areas and in her room. Resident #163 was harmed when she sustained a 3 centimeter laceration on her left eyebrow and needed to be repaired. The facility did not provide an adequate supervision she required.

Based on observation, policy review, resident and staff interview, and record review, it was determined the facility failed to ensure a method for evaluating a residents pain level and the effectiveness of residents' pain management plans for 4 of 6 residents (#39, #41, #46, and #60) reviewed for pain. Resident #46 was harmed when the facility did not provide adequate pain management to allow the resident to bathe more than once a week or to eat in comfort. Resident #60 was harmed when she exhibited verbal and nonverbal expressions of pain. This failure created the potential for harm for residents (#39, #41) experienced ongoing severe pain or increased pain. Findings include: The Facility's Pain Assessment and Management policy, dated (MONTH) (YEAR), documented pain management was defined as the process of alleviating a resident's pain to a level that was acceptable to the resident. The policy documented staff were to assess, recognize, and address residents' pain. The policy documented staff were to complete comprehensive pain assessments upon admission, quarterly, and as needed. 1. Resident #46 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A quarterly MDS assessment, dated 12/12/18, documented Resident #46 was cognitively intact and she required extensive assistance of one staff members with all cares except eating. The MDS documented Resident #46 had frequent pain ratings of eight, which affected her sleep and daily activities. Resident #46's record did not include a pain evaluation. Resident #46's physician orders [REDACTED].>- Tylenol 650 mg tablet daily for back pain, ordered on [DATE]. - Tylenol 650 mg tablet every four hours for pain PRN, ordered on [DATE]. - Monitor for pain every shift and PRN and document on the pain flowsheet every shift, ordered on [DATE]. The care plan area addressing Resident #46's pain, dated 5/28/18, documented staff were to provide Resident #46 with pain medications as ordered and monitor for effectiveness. Resident #46's MARs from 12/1/18 through 1/16/19, did not include documentation of daily pain ratings on a 1 to 10 scale or faces scale on 12/1/18 through 12/4/18, 12/6/18 through 12/30/18, 1/1/19, 1/2/19, 1/3/19, 1/5/19 through 1/9/19, and 1/12/19, 1/13/19. Resident #46's MARs from 12/1/18 through 1/16/19 documented she was administered her PRN Tylenol once on 12/4/18, 12/5/18, 12/7/18, 12/11/18 to 12/13/18, 12/17/18, 12/25/18, 12/29/18 to 12/31/18, 1/5/19, 1/6/19, 1/10/19 to 1/13/19, and 1/16/19, and twice on 1/2/19 to 1/4/19, and 1/7/19 to 1/9/19. The effectiveness of the PRN pain medication was not documented on 12/4/18, 12/5/18, 12/31/18, 1/2/19, 1/4/19, 1/7/19, 1/8/19, and 1/10/19. On 1/15/19 at 9:46 AM, Resident #46 was observed sitting in her recliner chair eating. Resident #46 was observed sitting in the same position on 1/15/19 at 10:09 AM, 10:37 AM, 11:25 AM, 12:15 AM, 2:46 PM, and 4:37 PM. Resident #46 stated no one visited her unless she used her call light to request something. On 1/15/19 at 10:19 AM, Resident #46 stated she had pain in her lower back and legs. Resident #46 stated her pain was usually around a seven and she wanted zero pain. Resident #46 stated she could only handle one shower a week because of her pain. Resident #46 stated staff provided pain medications when she asked for them. On 1/15/19 at 10:35 AM, LPN #4 was standing next to Resident #46 with her afternoon pills and Resident #46 asked LPN #4 for pain medication. LPN #4 stated she was going to add the pain medication to her afternoon pills and left the room. LPN #4 did not assess Resident #46's pain level before she left the room. On 1/15/19 at 10:36 AM, LPN #4 returned with Resident #46's medication and pain medication, Resident #46 asked LPN #4 how much Tylenol was in the cup and LPN #4 stated 650 mg which was ordered. Resident #46 asked if she could get more depending on the upper limit. LPN #4 stated she was going to check Resident #46's orders and discuss it with the doctor. On 1/16/19 at 10:12 AM, Resident #46 stated she was in too much pain to eat her food and started crying. On 1/17/19 at 12:53 PM, LPN #3 stated Resident #46 had extreme pain in her back and legs. LPN #3 stated she provided PRN pain medications when Resident #46 requested them. LPN #3 stated Resident #46 was able to verbalize her pain level. LPN #3 stated when a PRN pain medication was provided the staff documented the administration on the PRN pain flowsheet and assess the effectiveness in approximately 30 minutes. On 1/17/19 at 4:00 PM, the DNS was aware non-pharmacological interventions were not documented as completed when a resident was in pain and she was aware the efficacy of pain medications and residents' pain levels were not consistently documented. The DNS stated staff should document residents' pain levels on the PRN pain flowsheet for the scheduled and the PRN pain medication administrations. The DNS stated the facility's quality assurance committee was currently revising and reviewing their pain management program. 2. Resident #60 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Pain Evaluation, dated 6/9/17, documented Resident #60 had lots of pain and she was unable to verbalize a pain rating. The evaluation did not document an acceptable pain level for Resident #60. Resident #60 did not have a more recent pain evaluation in her record. A quarterly MDS assessment, dated 12/24/18, documented Resident #60 had a moderate cognitive impairment and she required extensive assistance from one to two staff members with all cares. The MDS documented Resident #60 had a constant pain rating of eight, which affected her sleep and daily activities. Resident #60's physician orders [REDACTED].>- [MEDICATION NAME] (a narcotic pain medication) 50 mg 1 tablet every 6 hours PRN for pain, use a pain scale of zero to ten or the face scale to rate the pain, ordered on [DATE]. - [MEDICATION NAME] 50 mg twice daily for pain, ordered on [DATE]. - Monitor for pain every shift and PRN and document on the pain flowsheet every shift, ordered 11/29/18. The care plan area addressing Resident #60's Pain, dated 2/16/15, documented staff were to complete pain assessments on admission and quarterly. The care plan documented staff were to assess Resident #60 for signs and symptoms of pain every shift, provide pain medications as needed, and provide non-pharmacological interventions as needed. Resident #60's 12/1/18 through 1/16/19 MARs did not include documentation of her daily pain rating on a 1 to 10 scale, or a rating using the faces scale. The MARs documented Resident #60 received PRN [MEDICATION NAME] once on 12/7/18, 12/16/18, 12/19/18, 1/2/19, 1/3/19, 1/5/19 through 1/8/19, 1/10/19, 1/12/19, and 1/13/19, and twice on 1/4/19 and 1/15/19. The Pain Management flowsheets for (MONTH) (YEAR) and (MONTH) 2019 did not include daily documentation Resident #60's pain level was assessed. There was no documentation on 12/1/18 to 12/6/18, 12/8/18 to 12/11/18, 1213/18 to 12/28/18, 12/30/18, 12/31/18, 1/2/19, 1/5/19, 1/8/19, The Pain Management flowsheets did not include the effectiveness of the PRN pain medication when it was given to Resident #60 on 12/19/18, 1/2/19, 1/4/19, 1/5/19, 1/6/19, 1/7/19, and 1/8/19. On 1/14/19 at 12:50 PM, Resident #60 was observed near the nurses' station sitting in her wheelchair with her back to the TV and her eyes were closed. Resident #60 was observed from 12:50 PM through 1:47 PM without changes until staff assisted her to the restroom and then into her bed. Resident #60 was observed saying, Ow and took a deep breath while CNA #7 assisted her into bed. On 1/15/19 at 4:33 PM, Resident #60 was observed sitting in her wheelchair and lifting her legs up in the air and saying, Help, help, help, help. A staff member assisted her into a lounge chair. The MAR indicated [REDACTED]. The resident was not medicated with her prn pain medication for 45 minutes. On 1/17/19 at 3:21 PM, Resident #60 was observed sitting in her wheelchair and lifting her legs up in the air and saying, Help, help, help, help. LPN #3 assisted Resident #60 into a lounge chair. The MAR indicated [REDACTED]. On 1/17/19 at 12:59 PM, LPN #3 stated Resident #60's pain was mostly in her legs and she raised her legs when she was in pain and said, help. LPN #3 stated Resident #60 was unable to verbalize what her pain level was, and staff knew her pain level from her facial expressions. LPN #3 stated if staff asked Resident #60 directly if she was in pain, Resident #60 said yes or no. On 1/17/19 at 3:56 PM, LPN #2 stated the unit managers completed residents' pain assessments quarterly with the MDSs. LPN #2 stated Resident #60's quarterly pain assessment was missed, and Resident #60 did not have a current assessment completed. LPN #2 stated Resident #60 verbalized when she was in pain. 3. Resident #41 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Pain Evaluation, dated 9/3/18, documented Resident #41 did not have pain at the time of the evaluation, and she was unable to verbalize a pain rating. The evaluation did not document an acceptable pain level for Resident #41. A quarterly MDS assessment, dated 12/3/18, documented Resident #41 had a severe cognitive impairment and she required extensive assistance from one to two staff members with all cares. The MDS documented Resident #41 received PRN and scheduled pain medications. Resident #41's physician orders [REDACTED].>- Tylenol one 500 mg tablet for a pain rating of one to five and two tablets for a pain rating of six to ten every four hours PRN for pain, ordered on [DATE]. - Monitor for pain every shift and PRN and document on the pain flowsheet every shift, ordered on [DATE]. Resident #41's care plan did not include a section for pain or pain management. Resident #41's Pain Management flowsheets from 12/1/18 through 1/16/19, documented Resident #41's daily pain rating was not documented on 12/1/18 to 1/10/19, 1/12/19, and 1/14/19 to 1/16/19. Resident #41's 12/1/18 through 1/16/19 MAR indicated [REDACTED]. The effectiveness of the PRN pain medication was not documented on the Pain Management flowsheet on 12/8/18, 12/14/18, 12/18/18, 12/25/18, 1/4/19, and 1/14/19. Resident #41's pain medication was not administered per her physician's orders [REDACTED].>- On 12/4/18 a pain rating was not documented, and 1000 mg of Tylenol was administered. - On 12/10/18 at 7:00 AM, Resident #41's pain was rated at a seven and 500 mg of Tylenol was administered not 1000 mg as ordered. - On 12/14/18 a pain rating was not documented, Tylenol was documented as given but the dose was not documented. - On 12/15/18 a pain rating was not documented, and 1000 mg of Tylenol was administered. - On 12/16/18 at 7:30 PM, Resident #41's pain was rated at a seven and 500 mg of Tylenol was administered not 1000 mg as ordered. - On 12/18/18 a pain rating was not documented, and 1000 mg of Tylenol was administered. - On 12/25/18 a pain rating was not documented, and 1000 mg of Tylenol was administered. On 1/14/19 from 12:17 PM to 2:15 PM, Resident #41 was observed sitting in the hallway with her back to the nurses' station. Resident #41 had a staff member near her periodically throughout the observation. Resident #41 was observed groaning and moaning when staff was not by her side, from 12:41 PM to 12:53 PM, at 1:04 PM and 1:06 PM, and from 1:11 PM to 1:43 PM. On 1/15/19 from 10:51 AM to 12:25 PM, Resident #41 was observed sitting with her back to the nurses' station and periodically staff sat next to her. Resident #41 was observed periodically moaning, groaning, and crying softly to herself. On 1/15/19 from 4:32 PM to 5:32 PM, Resident #41 was observed sitting in her wheelchair with her back to the nurses' station and periodically crying and moaning. On 1/16/19 at 10:18 AM, Resident #41 was observed in bed and cried out, Help, help, help. On 1/16/19 at 12:19 PM, Resident #41 was observed in her wheelchair with her back to the nurses' station and cried out, Help, help, help, help, help. On 1/17/19 at 11:00 AM, Resident #41 was observed in her wheelchair with her back to the nurses' station moaning and crying, Help, help, help, help, help. On 1/17/19 at 12:47 PM, LPN #3 stated Resident #41 moaned and cried often. LPN #3 stated when Resident #41's cried and moaned louder than normal staff thought she was in pain. LPN #3 stated if staff touched her and Resident #41 tensed up staff knew she was in pain. LPN #3 stated with Resident #41 staff utilized the facial pain rating scale. LPN #3 stated nurses were supposed to document residents' pain levels on the PRN pain management flowsheet. 4. Resident #39 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #39's physician orders [REDACTED]. A Physician's Progress Note, dated 6/4/18, documented Resident #39 reported lower back pain and difficulty walking. The progress note documented Resident #39 had chronic pain and was stable with current medications. An annual MDS assessment, dated 11/8/18, documented Resident #39 was cognitively intact. The MDS documented Resident #39 received both scheduled pain medication, and as needed pain medication. The MDS documented Resident #39 experienced almost constant pain with a pain level of five which affected her sleep and daily activities. The care plan area addressing Resident #39's Pain, dated 11/11/18, documented staff were to assess Resident #39 for signs and symptoms of pain every shift, provide pain medications as needed, and provide non-pharmacological interventions as needed (backrub, position change, environment change). Resident #39's 12/1/18 through 1/16/19 MAR, documented Resident #39 received PRN pain medication 49 times during the 47 day period. Resident #39's Pain Management Flowsheet for 12/1/18 through 1/16/19 did not include documentation the staff attempted alternative pain relief measures prior to administering pain medication to Resident #39. On 1/14/19 at 12:07 PM, Resident #39 stated she had frequent back pain, and added that the nurses do not offer any alternatives except the medication. On 1/16/19 at 11:58 AM, LPN #1 stated when the staff administer PRN pain medication, they are to document the pain medication administration on the resident's MAR. They are also to document the resident's pain level on the Pain Management Flowsheet. LPN #1 stated the staff are expected to try alternative pain relief measures prior to administering pain medication. LPN #1 confirmed Resident #39's documentation did not include the nurses attempted alternative pain relief measures prior to administering pain medication to Resident #39. On 1/16/19 at 2:34 PM, the DNS stated Resident #39's record did not include documentation the nurses attempted alternative pain relief measures prior to administering pain medication to Resident #39. The DNS stated she knew there was an issue with the staff not implementing alternative pain relief measures prior to administering PRN pain medications.

Based on observation, record review, and staff interview, it was determined the facility failed to prevent the development of avoidable pressure ulcers. This was true for 1 of 2 sample residents (#10) reviewed for pressure ulcers. Resident #10 was harmed when she developed pressure ulcers to the coccyx/sacrum area and the right heel. Findings include: Resident #10 was admitted to the facility with hospice care on 6/30/17 with multiple diagnoses, including failure to thrive, dementia, arthritis, and history of pressure ulcers to the buttocks. The admission MDS (Minimum Data Set) assessment, dated 7/7/17, documented Resident #10 had severely impaired cognition, required extensive assistance with ADL's (Activity of Daily Living), and at risk for pressure ulcers. An Admission Nursing Evaluation/Data Collection sheet, dated 6/30/17, documented Resident #10 had a history of [REDACTED]. The full body assessment, dated 6/30/17, documented on a body diagram, Resident #10 had 3 old pressure ulcer scars to left buttocks and 1 old pressure ulcer scar to right buttocks. Resident #10's bilateral heels were documented intact with 1-2 plus [MEDICAL CONDITION] in her feet. Resident #10's Admission Care Plan, undated, documented interventions for staff to implement as follows: * Follow facility skin care protocol. * Turn every 2 hours and as needed. * Preventative measures per protocol. * Report to charge nurse any redness or skin breakdown immediately. The facility's Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised March 2014, did not include any preventative measures. The MAR (Medication Assessment Record) or TAR (Treatment Assessment Record), dated July 2017, did not include weekly skin assessments to be completed by a licensed nurse. A physician progress notes [REDACTED].#10 had a history of [REDACTED]. The physician progress notes [REDACTED]. The physical examination documented Resident #10's skin was free of rashes and extremeties had no [MEDICAL CONDITION]. a. An Accident/Incident Report, dated 7/15/17, documented a licensed nurse removed an [MEDICATION NAME] dressing from Resident #10's sacrum and found an area that was dark purple in color to the coccyx/sacrum and faded to red at the edges. The measurements were 12 cm x 4 cm denuded area. An Interdisciplinary Progress Note by the Wound Nurse, dated 7/17/17, documented Resident #10 skin presented with a butterfly wound consistent with a Kennedy Ulcer. The pressure ulcer to the coccyx/sacrum area measured 12 cm x 4 cm with 40% of the wound was unstageable due to eschar. The foam dressing was saturated with dark brown malodorous (foul smelling) drainage. The Wound Nurse contacted the hospice nurse for treatment orders for the coccyx wound. When asked for their policy regarding a Kennedy Ulcer, the facility provided printouts of 2 pages of a PowerPoint presentation from 2008, and 3 pages from a blog in 2013. The facility's Pressure Ulcer/Skin Breakdown - Clinical Protocol, revised March 2014 and identified by the facility as their pressure ulcer policy, did not recognize or define a Kennedy Ulcer. The facility was unable to provide evidence-based research from a nationally recognized source that such an ulcer was recognized by any authoritative entity, or why such an ulcer would be completely unavoidable. A Hospice Interim Order, dated 7/17/17, documented Resident #10 had a Kennedy Terminal Stasis Ulcer to the coccyx/sacrum and the facility staff were to perform wound care dressing changes daily and as needed as follows: * Cleanse coccyx/sacrum wound with wound cleanser or normal saline, apply skin prep to peri wound area, apply calcium alginate AG and cover with a foam dressing to coccyx/sacrum wound daily and as needed. * Apply an alternating pressure air mattress with side bolsters. * Staff to reposition Resident #10 side to side every 2 hours with pillows for support. A Wound Care Flow Sheet, dated 7/17/17 through 8/22/17, documented Resident #10's coccyx/sacrum wound was assessed weekly by the Wound Nurse as follows: * 7/17/17 - Measurements (Length, Width, Depth): 12 cm x 4 cm, no undermining or tunneling, moderate amount of malodorous brown drainage, wound bed - redness in color with 40% eschar tissue, and had pain. * 7/24/17 - Measurements: 4.5 cm x 7 cm x 2.5 with 2 cm of undermining from 6 o'clock to 12 o'clock, large amount of brown malodorous drainage, wound bed - 35% redness and 65% eschar in color with necrotic tissue (dead), and had pain. * 8/1/17 - Measurements: 4.5 cm x 8.5 cm x 3 cm with 3 cm of undermining from 6 o'clock to 12 o'clock and tunneling between 1 and 2 o'clock with 0.5 cm, large amount of brown malodorous drainage, wound bed - 30% redness and 70% eschar in color with necrotic tissue, and had pain. * 8/8/17 - Measurements: 5 cm x 9.2 cm x 3 cm with 3 cm of undermining from 6 o'clock to 12 o'clock and tunneling had increased to 1 cm, large amount of brown drainage with a slight odor, wound bed - 20% redness and 80% yellow in color with necrotic tissue, and pain with turning. * 8/15/17 - Measurements: 5 cm x 9.2 cm x 3 cm with increased undermining to 3.1 cm and tunneling to 1.1 cm, moderate amount of brown drainage with no odor, wound bed - 100% yellow slough in color with necrotic tissue, and no pain to the wound. * 8/22/17 - Measurements: 4.3 cm x 9 cm x 3.5 cm with undermining of 3.5 and tunneling 1.0 cm, moderate brown drainage, wound bed - 10% redness and 90% yellow slough in color with necrotic tissue, and no pain to the wound. On 8/23/17 at 3:15 pm, the Wound Nurse was observed changing the dressing to Resident #10's coccyx/sacrum wound. The Wound Nurse said the pressure ulcer was measured on 8/22/17 with the hospice nurse. The wound was shaped like a butterfly. The wound bed was observed with granulating tissue approximately 9 cm in length, 5 cm width with gray and black tissue, and 4 cm depth with undermining between 6 o'clock to 12 o'clock and tunneling at 1-2 o'clock. A moderate amount of brown drainage was on the old dressing with no odor noted. The Wound Nurse said the pressure ulcer was increasing in size weekly, because it's a Kennedy Ulcer, the wound wouldn't heal because Resident #10 was on hospice and her life expectancy was less than six months. On 8/24/17 at 9:45 am, the DNS said Resident #10's Admission Care Plan documented staff was turning Resident #10 side to side every 2 hours and as needed. The DNS was unable to find documentation for additional preventative measures to prevent the development of Resident #10's coccyx/sacrum pressure ulcer. The DNS said the pressure ulcer was unavoidable because Resident #10 was on hospice and the hospice agency diagnosed the pressure ulcer as a Kennedy Ulcer. On 8/24/17 at 12:15 am, the Wound Nurse said the hospice agency didn't think Resident #10 needed an air mattress when she was admitted to the facility on [DATE]. The Wound Nurse said she was educated by the Administrator on 7/17/17, when the pressure ulcer developed, that the facility was responsible for Resident #10's plan of care not the hospice agency. b. A Physician Order, dated 7/20/17, documented heel lift boots and skin prep to bilateral heels twice a day for Resident #10. Resident #10's treatment administration record (TAR) included an area to document the provision of those treatments each morning and evening. The TAR was blank in the area for the morning administration of those interventions between 7/20/17 and 7/23/17. An Interdisciplinary Progress Note by the Wound Nurse, dated 7/24/17, documented Resident #10 had a fluid filled blister to her right heel. The measurements were 3.5 cm x 3.0 cm. An Interdisciplinary Progress Note by the Wound Nurse, dated 8/1/17, documented Resident #10's blister to right heel was black eschar and intact. No measurements were documented. An Interdisciplinary Progress Note by the Wound Nurse, dated 8/8/17, documented Resident #10's blister to right heel measured 1.0 cm x 1.1 cm intact with black eschar and resolving. An Interdisciplinary Progress Note by the Wound Nurse, dated 8/15/17, documented Resident #10's blister to right heel was a stable, flat, and a dry scab. No measurements were documented. An Interdisciplinary Progress Note by the Wound Nurse, dated 8/22/17, documented Resident #10's blister to right heel remains flat and a dry scab. No measurements were documented. On 8/23/17 at 3:15 pm, Resident #10 was observed in bed with heel lift boots to bilateral feet. On 8/24/17 at 12:15 pm, the Wound Care Nurse said Resident #10's right heel blister was found on 7/24/17, but the staff had been offloading her heels with pillows when she was admitted on [DATE]. The Wound Nurse was unable to find documentation in the clinical record for staff to offload Resident #10's heels. The Wound Nurse said after the right heel blister was found, the facility received orders for Resident #10 to wear heel lift boots and apply skin prep to bilateral heels twice a day. The Wound Nurse said the right heel blister was healing when the heel lift boots were initiated. On 8/24/17 at 4:00 pm, LPN #4 was observed removing Resident #10's heel lift boots bilaterally. The right outer aspects of Resident #10's right heel had an approximately 1.0 cm x 1.0 cm black scab. The edges of the wound bed were intact without drainage. LPN #4 re-applied the heel lift boots to bilateral feet and placed a pillow under Resident #10's legs to offload her heels. LPN #4 said since Resident #10 wears the bilateral heel lift boots that the staff doesn't always need to offload her heels. Resident #10 was admitted to the facility with a history of pressure ulcers to her buttocks. Resident #10 was harmed when the facility failed to identify and implement effective preventative measures, such as an air mattress and to offload her heels. Resident #10 developed two pressure to her coccyx/sacrum area and to her right heel.

Based on interview, and record review, it was determined the facility failed to provide appropriate supervision to prevent accidents for 1 of 15 residents (#2). Resident #2 was harmed when she left the facility into an outdoor courtyard without adequate supervision, fell , and sustained an arm and hip fracture. Findings include: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's annual Minimum Data Set (MDS) assessment, dated 2/24/17, documented she was severely cognitively impaired, required set-up and assistance with ambulation, and extensive assistance of two persons for transfers. The MDS documented Resident #2 was not steady, but could stabilize without staff assistance for walking and turning around. The Care Area Assessment (CAA) for Resident #2's Activities of daily living documented the resident exhibited balance problems and, staggers at times will tip forward if she bends over to pick up an item off the floor. On 1/26/16, Resident #2's care plan documented she was at risk of elopement. Interventions included keeping Resident #2 in line of sight when out of the room. On 1/30/16, Resident #2's fall risk care plan documented she was at risk for falls related to wandering and the use of anti-seizure and antianxiety medications. The interventions included placing the resident on the facility's Falling Star Program, to increase staff awareness that she was at risk for falls. On 2/24/17, a Fall Risk Evaluation for Resident #2 documented she was at high risk for falls. On 5/5/17, a Resident Incident Report for Resident #2 documented the resident sustained [REDACTED]. The report documented a CNA was walking with the resident at the time, but was unable to direct or guide her to prevent the resident from walking into the window. On 5/17/17, Resident #2's elopement care plan was updated to document she required line of sight supervision when up throughout the unit, instead of out of her room. Resident #2's physician's orders [REDACTED]. Resident #2's Medication Administration Record (MAR) for May 2017 documented the resident received a dose of Klonopin on 5/23/17 at 12:45 pm. Medication literature for Klonopin (https://www.drugs.com/klonopin.html) documented, The sedative effects of Klonopin may last longer in older adults. Accidents are common in elderly patients who take benzodiazepines. Use caution to avoid falling or accidental injury while you are taking Klonopin. On 5/23/17 at 5:25 pm, a Resident Incident Report documented Resident #2 was discovered to have fallen in the courtyard. The fall was documented as unwitnessed, but CNA #8 saw the resident face down on the cement ramp outside leading to the courtyard through the window, and alerted the LN on duty. CNA #8's statement on the report stated the resident was on visual precautions at the time the fall occurred, which meant the resident should always be visible to staff. On 5/23/17 a Fall Scene Investigation Report for Resident #2 documented she was confused at the time of the fall, and had received antianxiety medication within 8 hours prior to the fall. A 5/23/17 hospital progress note for Resident #2 documented the resident had sustained a stable, comminuted humeral head (upper arm) fracture. A 5/26/17 hospital progress note documented Resident #2 had also sustained a left femoral neck (hip) fracture as a result of the 5/23/17 fall, which required surgical repair. On 5/29/17, the facility completed an Incident and Accident Report for Resident #2's 5/23/17 fall. The report documented the facility Administrator had determined the fall to be unavoidable. The facility's Safety and Supervision of Residents policy, dated 12/2007, documented, implementing interventions to reduce accident risks and hazards shall include the following .d. ensuring interventions are implemented .monitoring the effectiveness of the interventions shall include the following .c. modifying or replacing interventions as needed. On 8/21/17 at 10:55 am, LPN #1 stated Resident #2 had a fall a few months ago, and sustained an arm and hip fracture. LPN #1 stated the resident was in the courtyard outside the secured unit where she lived, and had an unwitnessed fall. LPN #1 stated although Resident #2 should have been in the staff's line of sight at the time of the fall, she was not. On 8/24/17 at 11:20 am, the Administrator said the line of sight intervention on Resident #2's care plan no longer applied to her after she was moved from the behavioral hall to the secured unit. The Administrator stated Resident #2 was not at risk for falls and was able to ambulate independently. The Administrator was unable to explain how it had been determined the resident was not at risk for falls, when her fall risk assessment documented her fall risk as high. On 8/25/17 at 12:25 pm, the Behavioral Unit Care Manager (BUCM) stated Resident #2 was moved to the secured unit on 5/17/17 (6 days prior to the fall) because the resident had exit seeking and elopement behaviors. The BUCM stated the staff and family decided moving Resident #2 to the secured unit would give her the freedom to move in and out of the courtyard without needing to be redirected. The BUCM stated the elopement care plan was left in place until staff became familiar with Resident #2, and staff knew to have her in line of sight when she went off of the secured unit for activities. The BUCM said all the residents on the secured unit had 15 minute safety checks. The BUCM stated Resident #2 could ambulate independently and did not require assistance. On 8/25/17 at 4:45 pm, the MDS nurse stated Resident #2 was coded to require supervision during ambulation on the most recent MDS. The MDS nurse stated the resident could ambulate on her own, but needed staff to supervise her because the resident had a tendency to stumble. Both the MDS nurse and the assistant MDS nurse stated Resident #2 should not have been unsupervised when ambulating outside on 5/23/17, especially after receiving Klonpin earlier that day. Resident #2 was harmed when the facility failed to adequately supervise a confused resident with a recent environmental change, assessed at baseline to be at high risk for falls, with an unsteady gait, and required supervision with ambulation. The resident suffered an unwitnessed fall outside the facility within 6 hours of receiving an antianxiety medication. The resident sustained [REDACTED].

Based on observation, staff interview and record review, it was determined the facility failed to ensure residents received nutritional interventions to prevent unplanned weight loss. This was true for 1 of 4 residents (#5) reviewed for weight loss. Resident #5 was harmed when she experienced a 7.5% weight loss in one month, a 5.8 % weight loss a week later and another 3.7% weight loss a week after that. Findings include: Resident #5 was admitted to the facility in 2013 and readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment, dated 7/28/17, documented Resident #5 was understood by others, usually understood others, had moderate cognitive impairment, required extensive assistance with eating, and had unplanned weight loss. Interventions in Resident #5's alteration in nutritional/fluid intake/potential dehydration care plan, originated 6/30/15, included: * If resident does not initiate self eating staff to assist with meals; * Dining program breakfast and lunch; * Tires easily, staff to start meal with supplement first; * Small plates for individual food items, due to gets overwhelmed easily; * High calorie ice cream lunch and dinner; and * Boost pudding with breakfast and lunch. The resident's 8/4/17 ADL (Activities of Daily Living) Care Plan instructions to Certified Nursing Assistants and Restorative Aides (RA) documented: * Nosey cups with meals; * Start meal with supplement first then small plates for individual food items; * Restorative dining program set up; and, * If does not initiate self eating staff to assist with meal. Resident #5's August 2017 physician's orders [REDACTED]. A 7/20/17 fax (facsimile) to the physician documented, Resident is down another 7# (pounds) in 1 month and asked if an appetite stimulant would be appropriate. On 8/3/17, the physician ordered [MEDICATION NAME] every day to help appetite and Boost supplement 1 can with each meal as tolerated. On 8/22/17 at 12:05 pm, Resident #5 and 3 other residents were observed at a table in the restorative area of the dining room. CNA #5 was seated across the table from Resident #5 and another CNA set-up Resident #5's meal then left the area. The resident's meal consisted of 6 small bite size pieces of ham, a teaspoon size portion of green peas and a tablespoon size portion of mashed potatoes with gravy on a saucer. This saucer was directly in front of the resident and it was surrounded by 4 nosey cups of liquids, a dinner roll in a bowl, 1 unopened Boost pudding cup, 1 unopened box of liquid Boost and a piece of cake on a saucer wrapped in clear plastic. There was no ice cream on the table for Resident #5. On 8/22/17, from 12:06 pm to 12:20 pm, CNA #5 verbally cued Resident #5 several times about the food items on the saucer and the drinks on the table. The resident took 2 tiny bites of mashed potatoes and gravy but did not eat or drink anything else. At 12:20 pm, the Speech Therapist (ST) talked with the resident about the cake, which he unwrapped and placed in front of her. The ST verbally cued the resident to eat the cake, then he left the area. CNA #5 verbally cued the resident again but the resident did not eat or drink anything. At 12:32 pm, the resident still had not eaten or drunk anything and the Director of Therapy offered to take her to her room. The resident declined. By 12:44 pm, all of the other residents had left the area and CNA #5 moved next to Resident #5. The CNA asked the resident if she would like help, then opened the liquid Boost, offered it to the resident and the resident took several sips. At 12:47 pm, the CNA fed the resident 2 bites of ham then opened the pudding and put a spoon in it. The resident did not attempt to eat the pudding. At 12:49 pm, the CNA fed her 2 bites of the pudding to the resident, after which the resident said she was finished. Resident #5 did not attempt to feed herself during the lunch meal on 8/22/17, other than 2 tiny bites, and the staff did not offer or provide her with eating assistance for 38 minutes. Staff did not start the meal with a nutritional supplement, and ice cream was not provided as care planned. On 8/24/17 at 12:15 pm, Resident #5 and 3 other residents were observed at a table in the restorative area of the dining room. CNA #5 was seated across the table from Resident #5. The ST was standing next to Resident #5. The resident's meal was already on the table, it consisted of a piece of pizza on a saucer, which was in front of the resident. The pizza was surrounded by 3 bowls of food, 1 Boost pudding cup, 1 ice cream cup, 6 nosey cups of liquids, a strawberry health shake box and an unopened box of liquid Boost. The resident did not attempt to eat or drink anything. On 8/24/17 at 12:20 pm, the ST verbally cued Resident #5 to eat some soup and/or ice cream, then he left the area. At 12:26 pm, CNA #5 opened the liquid Boost and placed it in front of the resident. The resident took 3 sips of the Boost, but did not attempt to feed herself. At 12:32, CNA #4 verbally cued the resident to eat the soup. The resident said, It's hot, but made no effort to eat the soup. At 12:37 pm, the CNA verbally cued the resident to eat the dessert. The resident ate 1 bite of the cranberry bar with whipped cream. The resident closed her eyes on and off during the meal. At 12:43 pm, CNA #4 asked RN #1 to assist the resident. At 12:44 pm, RN #1 sat by the resident and asked her what she would like to eat. The resident chose ice cream. RN #1 left the table briefly, then returned at 12:45 pm, and began feeding the resident. The resident ate most of the ice cream, 2 bites of dessert and drank several sips of the liquid Boost. The resident also drank 1 sip of the strawberry health shake and said she did not like it. A Feeder Training Program (restorative dining) from 8/1/17 to 8/24/17 documented: * Resident #5 was independent using a spoon and a glass during breakfast and lunch, except on 8/24/17 during lunch when she was noted as dependent and independent. * Breakfast food intake was 15% twice, 10% six times, 5% eleven times, and not recorded four times. * Lunch food intake was recorded once at 75%, 60%, 40%, 35% and 30%, four times at 50% (including 8/24/17), six times at 25%, three times at 20%, twice at 10% (including 8/22/17), twice at 5%, and not recorded twice. * Lunch fluid intake was recorded once for the following amounts: 360 cc, 340 cc, 270 cc, 240 cc and 80 cc; three times at 200 cc, four times at 180 cc, five times at 120 cc, five times at 100 cc, and not recorded twice. Resident #5's Nutrition Risk Review Progress Notes included the following documentation: * 7/25/17 - Weight loss of 6.9 pounds (7.5%) over 1 month, from 6/19/17 (93 pounds) to 7/18/17 (86 pounds). The Interdisciplinary Team (IDT) recommended an appetite stimulant and (a [DIAGNOSES REDACTED]. * 8/1/17 - Another 5 pound (5.8%) weight loss in 1 week, from 7/18/17 (86 pounds) to 7/25/17 (81 pounds). The IDT was awaiting MD (physician) response . * 8/8/17 - Another 3 pound (3.7%) weight loss in 1 week, from 7/25/17 (81 pounds) to 8/1/17 (78 pounds). The IDT recommendation was to continue with failure to thrive per MD. * 8/15/17 - A 1 pound weight gain in 2 weeks, from 8/1/17 (78 pounds) to 8/14/17 (79 pounds). The IDT continued to monitor the resident. * 8/22/17 - No change, the resident's weight remained at 79 pounds from 8/14/17 to 8/22/17 and the IDT continued to monitor the resident. On 8/24/17 at 3:10 pm, the Certified Dietary Manager (CDM) said the resident had significant weight loss and was placed back on RAR (Resident at Risk) committee review in July. On 8/25/17 at 11:35 am, CNA #5 said it was 30 minutes and longer before staff assisted Resident #5 to eat during lunch on 8/22/17 and 8/24/17. She added that on 8/24/17 the resident ate almost all of the ice cream and drank more Boost when staff assisted her to eat. CNA #5 said the resident gets upset when people try to feed her but that was not the case at lunch on 8/24/17 and the resident did good. Resident #5 was harmed when she experienced severe weight loss between 6/1/17 and 8/8/17. The facility failed to consistently implement the plan of care.

Based on observation, resident and staff interview, facility policy/procedure review, and record review, it was determined the facility failed to thoroughly investigate allegations of abuse and/or neglect, and injuries of unknown origin. This was true for 2 of 8 sampled residents (#1 and #4) reviewed for accidents and supervision and for one random resident (#16) who filed a grievance with the facility alleging a staff member had verbally abused and intentionally intimidated her. Specifically: a) Resident #16 filed a grievance with the facility on 9/27/16 that alleged a specific staff member had verbally abused and intimidated her. The staff member was reassigned and continued to care for other residents; an investigation into the allegation was not conducted and the allegation was not reported to the State Agency. The identified staff member was observed on duty in the facility on 12/1/16. The resident who filed the 9/27/16 grievance stated she continued to be fearful of the staff member and still felt she had been verbally abused and intimidated. b) Resident #4 was assessed on 11/1/16 with bruises to her right forearm that were depicted by the facility as arranged in a pattern consistent with fingerprint bruising. The staff member who reported the bruising surmised the resident's arms had been held by staff while cares were provided. There was no evidence the facility investigated this statement further to eliminate abuse as the possible cause of the bruising. The facility concluded the injury was self-inflicted. c) Resident #1, who was equipped with a restraint belt to her wheelchair, was assessed on 9/14/16 with a large hematoma on her outer thigh. The facility failed to provide evidence the injury was investigated. The facility attributed the hematoma to an injection Resident #1 received six days prior to the appearance of the injury. The failure of the facility to identify and thoroughly investigate the above incidents placed Residents #1, #4, and #16, and other residents with injuries of unknown origin, and residents who came in contact with the staff member accused of verbal abuse and intimidation, in immediate jeopardy of serious harm, impairment, or death. Findings include: The facility's Abuse & Neglect Prevention Training Program, dated 11/19/16, documented protocols and procedures for all staff related to Prevention, Identification, Investigation, Protection, (and) Reporting of abuse, neglect, and misappropriation of property. Training Program materials were determined to be compliant and consistent with related federal regulations and included the following: * Indicators of Abuse and Neglect * Abuse Definitions * Predicting Abusive Behavior * Understanding Stress and Abusive Behavior * Catastrophic Reactions * Behavioral Causes and Interventions * Reporting Abuse to Facility Management * Abuse Prohibition * Videotaping, Photographing, and Other Imaging of Residents * Resident-to-Resident Altercations * Abuse and Neglect - Clinical Protocol * Abuse Investigations * Abuse Prevention Program * Preventing Resident Abuse 1. Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #16's Mood/Behavioral Alteration Care Plan, dated 9/21/16, documented: * Resident's behaviors and attempts to manipulate will not interfere with care delivery.* Resident will experience a stable and comfortable environment. * Be alert for attempts to manipulate that are really bids for additional attention. * Do not accept resident accounts of others' statements, behaviors; deal directly with individual. A September 2016 Monthly Behavior Summary documented Resident #16 exhibited 28 episodes of anxiety with distress that month, 6 episodes of delusions with distress, 8 episodes of delusions without distress, 9 incidents of verbal aggression, 2 incidents of physical aggression, 12 episodes of socially inappropriate behavior, 5 episodes of resistance to care, 2 incidents of hallucinations with distress, 5 incidents of hallucinations without distress, and 15 incidents of paranoia. The September 2016 Monthly Behavior Summary documented Resident #16 on 9/26/16 experienced two episodes of anxiety with distress and a single episode each of socially inappropriate behavior and paranoia. On 9/27/16, the Monthly Summary documented Resident #16 experienced 1 episode each of anxiety with distress and delusions without distress. A Physician's Telephone Order, dated 9/26/16, documented Resident #16 was admitted to the facility's Behavior Program per IDT assessment. On 9/27/16, Resident #16 filed a Grievance/Complaint Report with the facility alleging CNA #4 was verbal(ly) abusive and intimidated her during cares. The Grievance/Complaint Report did not include evidence of an investigation. The Report documented CNA #4 was relocated to another area of the facility where she would not come into contact with Resident #16. A Care Conference Report, dated 9/27/16, documented Resident #16 was admitted to the Behavior Care Program due to her socially inappropriate behaviors and that she continued to exhibit behaviors that require a significant amount of 1:1 (staff) time and attention. On 12/1/16 at 8:25 am, CNA #4 identified how to recognize, respond to, and report suspected abuse and/or neglect and stated she and all facility staff received abuse prevention training annually. On 12/1/16 at 9:50 am, the Administrator, who also served as the facility's Abuse Prevention Coordinator, stated both he and Resident #16 remembered and had recently discussed the 9/27/16 incident. The Administrator stated Resident #16's report of verbal abuse and intimidation by CNA #4 was not processed according to the facility's policy or normal procedure because he had not been shown Resident #16's written statement. The Administrator stated he also did not personally initiate an investigation into the allegation of verbal abuse and intimidation as the Grievance/Complaint Report documented Resident #16 was satisfied with CNA #4's reassignment to another area of the facility. On 12/1/16 at 10:45 am, the DON stated she did not recall seeing Resident #16's written statement regarding the 9/27/16 incident either, but spoke with both Resident #16 and CNA #4 at the time and considered the matter resolved to Resident #16's satisfaction. On 12/1/16 at 10:50 am, Resident #16 stated she remembered the 9/27/16 incident with CNA #4, still considered CNA's behavior that day as verbally abusive and intimidating. She said, I'm just actually afraid of her. I wouldn't want anyone else to go through what I've been through with her (CNA #4). An investigation into Resident #16's allegation was not conducted and the allegation was not reported to the State Agency. The facility failed to operationalize its abuse and neglect policy and procedures. 2. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #4's quarterly MDS assessment, dated 9/9/16, documented her cognition was severely impaired, she rarely/never made decisions, she was verbally aggressive, rejected cares, and exhibited behaviors of hitting and scratching herself. A Resident Incident Report for Resident #4, dated 11/1/16 at 2:30 am, documented, Found 4 bruises. Bruise to inner right forearm 3 x 2.25 cm. Bruises to outer right forearm approx 1 x 1 cm, 1.5 x 1 cm, 1.25 x 1 cm. A staff statement, dated 11/1/16 at 2:30 am, documented: It looked like fingerprints from someone's hand. I went and got (Nurse) to come take a look. I believe these may have happened from someone giving cares and holding on to (Resident #4's) arm. The facility's incident report body diagram illustrated the bruises were arranged in a pattern consistent with fingerprint bruising. An undated Follow up Incident Report Impaired Skin documented Resident #4 was combative and resistive to cares. A Behavior Monitor for 10/31/16 documented the resident exhibited striking out, pinching, kicking, and pushing, and had been known to squeeze her own forearms hard when upset. It was determined the bruising was reasonably related to event. The report was signed by RN UM #1 and the Administrator. There was no documentation the facility investigated further to rule out abuse. On 12/1/16 at 8:10 am, RN UM #1 stated she interviewed and assessed Resident #4 and did not think the bruising looked like fingerprints. RN UM #1 produced a document that noted staff were interviewed, however, no other individual staff statements were provided. On 12/1/16 at 9:45 am, the Administrator stated he reviewed the accident/incident reports and allegations of abuse reports prior to signing them. Referring to the 11/1/16 Resident Incident Report, he stated he had not signed it because he had not reviewed it. The Administrator stated If I had read this, I would have investigated it to rule out abuse. Should have caught that statement regarding the fingerprints. The facility failed to follow its Abuse Prevention policy. 3. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION]'s Chorea, dementia, and anxiety. The 8/5/16 quarterly MDS assessment documented Resident #1 had modified independence for daily decision making. Resident #1's September 2016 MAR documented an order on 9/10/15 for 75 mg IM every 2 weeks [MEDICATION NAME] Docanoate for [MEDICAL CONDITION]'s Chorea. Resident #1's September 2016 Physician order [REDACTED]. The padded leg strap was observed throughout the survey attached around Resident #1's upper legs, and underneath and behind her wheelchair. The September 2016 MAR documented the IM [MEDICATION NAME] Docanoate was administered to Resident #1's right hip on 9/8/16. Resident #1's 9/14/16 Progress Note documented, Res(ident) noted to have 10 cm (by) 7 cm reddened area to R(ight) outer thigh (with) firm round center appears non tender to touch (no) bruising or open areas; (Physician) here to eval(uate) (Family Member) also present, states hematoma that should resolve n(o) n(ew) o(rders) re(ceive)d . Resident #1's Incident Report, dated 9/14/16, documented: On 9/14/16 Nurse noted a 10 cm (by) 7 cm oval area of redness with a firm lump in center on (Resident #1's) right upper thigh. (Resident #1) had no idea what had happened. (Resident #1) does move around a lot at times due to her [MEDICAL CONDITION]'s chorea. MAR revealed that (Resident #1) was given her [MEDICATION NAME] injection 9/12/16 on right hip .(Nurse) was a traveling nurse and has finished her contract with us. I was unable to contact her regarding the injection. Family and Hospice were notified. Hospice ordered warm packs to area. Area is resolving. The documentation did not include information ruling out Resident #1's leg restraint as a source of the injury. An undated and unsigned document provided by the facility on 12/1/16, documented, Interviewed (2 CNAs) regarding bump on thigh. They thought it could be from her attempting to throw herself out of her w/c or roll up to mat. Talked to (Nurse) who came in to assess res(ident). She thought it was an encapsulate from [MEDICATION NAME] IM . The facility's completed abuse investigations from June 2016 to November 2016 did not include documentation related to the above issue. On 12/1/16 at 8:35 am and 9:10 am, the Behavior Unit Manager said she interviewed two CNAs and a nurse, but did not have witness statements for them. She said Resident #1's leg restraint was ruled out as a source of the injury due to the location of the hematoma, which said was likely caused by the [MEDICATION NAME] injection. She reviewed the MAR and said the IM [MEDICATION NAME] was given to the right hip on 9/8/16, and not on 9/12/16, as the report documented. She said had she realized the discrepancies at the time of the investigation she would have investigated the incident as an injury of unknown origin and followed the facility's abuse policy and procedures. On 12/1/16 at 9:25 am, the Administrator reviewed the investigation and said based on the information in the report, he could not determine the cause of the hematoma and it should have been investigated more thoroughly to rule out abuse. He said there were not witness statements or other investigative materials attached as required by the facility's abuse policy. NOTIFICATION AND REMOVAL OF IMMEDIATE JEOPARDY: On 12/1/16 at 12:25 pm, the facility's Administrator was informed the deficient practices placed the identified residents, and other residents with injuries of unknown origin or who came into contact with the staff member accused of verbal abuse and intimidation, in Immediate Jeopardy of serious harm, impairment, or death. On 12/1/16 at 7:35 pm, the facility provided an acceptable immediate jeopardy removal plan to address findings at F225 and F226. Please refer to F225 for key elements of the plan. Implementation of the plan was verified on-site and the facility informed on 12/1/16 at 8:20 pm, that the immediate jeopardy was removed.

Based on observation, resident and staff interview, facility policy/procedure review, and record review, it was determined the facility failed to thoroughly investigate allegations of abuse and/or neglect, and injuries of unknown origin. This was true for 2 of 8 sampled residents (#1 and #4) reviewed for accidents and supervision and for one random resident (#16) who filed a grievance with the facility alleging a staff member had verbally abused and intentionally intimidated her. Specifically: a) Resident #16 filed a grievance with the facility on 9/27/16 that alleged a specific staff member had verbally abused and intimidated her. The staff member was reassigned and continued to care for other residents; an investigation into the allegation was not conducted and the allegation was not reported to the State Agency. The identified staff member was observed on duty in the facility on 12/1/16. The resident who filed the 9/27/16 grievance stated she continued to be fearful of the staff member and still felt she had been verbally abused and intimidated. b) Resident #4 was assessed on 11/1/16 with bruises to her right forearm that were depicted by the facility as arranged in a pattern consistent with fingerprint bruising. The staff member who reported the bruising surmised the resident's arms had been held by staff while cares were provided. There was no evidence the facility investigated this statement further to eliminate abuse as the possible cause of the bruising. The facility concluded the injury was self-inflicted. c) Resident #1, who was equipped with a restraint belt to her wheelchair, was assessed on 9/14/16 with a large hematoma on her outer thigh. The facility failed to provide evidence the injury was investigated. The facility attributed the hematoma to an injection Resident #1 received six days prior to the appearance of the injury. The failure of the facility to identify and thoroughly investigate the above incidents placed Residents #1, #4, and #16, and other residents with injuries of unknown origin, and residents who came in contact with the staff member accused of verbal abuse and intimidation, in immediate jeopardy of serious harm, impairment, or death. Findings include: The facility's Abuse & Neglect Prevention Training Program, dated 11/19/16, documented protocols and procedures for all staff related to Prevention, Identification, Investigation, Protection, (and) Reporting of abuse, neglect, and misappropriation of resident property. Training Program materials were determined to be compliant and consistent with related federal regulations. 1. Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #16's Mood/Behavioral Alteration Care Plan, dated 9/21/16, documented: * Resident's behaviors and attempts to manipulate will not interfere with care delivery.* Resident will experience a stable and comfortable environment. * Be alert for attempts to manipulate that are really bids for additional attention. * Do not accept resident accounts of others' statements, behaviors; deal directly with individual. A September 2016 Monthly Behavior Summary documented Resident #16 exhibited 28 episodes of anxiety with distress that month, 6 episodes of delusions with distress, 8 episodes of delusions without distress, 9 incidents of verbal aggression, 2 incidents of physical aggression, 12 episodes of socially inappropriate behavior, 5 episodes of resistance to care, 2 incidents of hallucinations with distress, 5 incidents of hallucinations without distress, and 15 incidents of paranoia. The September 2016 Monthly Behavior Summary documented Resident #16 on 9/26/16 experienced two episodes of anxiety with distress and a single episode each of socially inappropriate behavior and paranoia. On 9/27/16, the Monthly Summary documented Resident #16 experienced 1 episode each of anxiety with distress and delusions without distress. A Physician's Telephone Order, dated 9/26/16, documented Resident #16 was admitted to the facility's Behavior Program per IDT assessment. On 9/27/16, Resident #16 filed a Grievance/Complaint Report with the facility alleging CNA #4 was verbal(ly) abusive and intimidated her during cares. The Grievance/Complaint Report did not include evidence of an investigation. The Report documented CNA #4 was relocated to another area of the facility where she would not come into contact with Resident #16. A Care Conference Report, dated 9/27/16, documented Resident #16 was admitted to the Behavior Care Program due to her socially inappropriate behaviors and that she continued to exhibit behaviors that require a significant amount of 1:1 (staff) time and attention. On 12/1/16 at 8:25 am, CNA #4 identified how to recognize, respond to, and report suspected abuse and/or neglect and stated she and all facility staff received abuse prevention training annually. On 12/1/16 at 9:50 am, the Administrator, who also served as the facility's Abuse Prevention Coordinator, stated both he and Resident #16 remembered and had recently discussed the 9/27/16 incident. The Administrator stated Resident #16's report of verbal abuse and intimidation by CNA #4 was not processed according to the facility's policy or normal procedure because he had not been shown Resident #16's written statement. The Administrator stated he also did not personally initiate an investigation into the allegation of verbal abuse and intimidation as the Grievance/Complaint Report documented Resident #16 was satisfied with CNA #4's reassignment to another area of the facility. On 12/1/16 at 10:45 am, the DON stated she did not recall seeing Resident #16's written statement regarding the 9/27/16 incident either, but spoke with both Resident #16 and CNA #4 at the time and considered the matter resolved to Resident #16's satisfaction. On 12/1/16 at 10:50 am, Resident #16 stated she remembered the 9/27/16 incident with CNA #4, still considered CNA's behavior that day as verbally abusive and intimidating. She said, I'm just actually afraid of her. I wouldn't want anyone else to go through what I've been through with her (CNA #4). An investigation into Resident #16's allegation was not conducted and the allegation was not reported to the State Agency. 2. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #4's quarterly MDS assessment, dated 9/9/16, documented her cognition was severely impaired, she rarely/never made decisions, she was verbally aggressive, rejected cares, and exhibited behaviors of hitting and scratching herself. A Resident Incident Report for Resident #4, dated 11/1/16 at 2:30 am, documented, Found 4 bruises. Bruise to inner right forearm 3 x 2.25 cm. Bruises to outer right forearm approx 1 x 1 cm, 1.5 x 1 cm, 1.25 x 1 cm. A staff statement, dated 11/1/16 at 2:30 am, documented: It looked like fingerprints from someone's hand. I went and got (Nurse) to come take a look. I believe these may have happened from someone giving cares and holding on to (Resident #4's) arm. The facility's incident report body diagram illustrated the bruises were arranged in a pattern consistent with fingerprint bruising. An undated Follow up Incident Report Impaired Skin documented Resident #4 was combative and resistive to cares. A Behavior Monitor for 10/31/16 documented the resident exhibited striking out, pinching, kicking, and pushing, and had been known to squeeze her own forearms hard when upset. It was determined the bruising was reasonably related to event. The report was signed by RN UM #1 and the Administrator. There was no documentation the facility investigated further to rule out abuse. On 12/1/16 at 8:10 am, RN UM #1 stated she interviewed and assessed Resident #4 and did not think the bruising looked like fingerprints. RN UM #1 produced a document that noted staff were interviewed, however, no other individual staff statements were provided. On 12/1/16 at 9:45 am, the Administrator stated he reviewed the accident/incident reports and allegations of abuse reports prior to signing them. Referring to the 11/1/16 Resident Incident Report, he stated he had not signed it because he had not reviewed it. The Administrator stated If I had read this, I would have investigated it to rule out abuse. Should have caught that statement regarding the fingerprints. 3. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses, including [MEDICAL CONDITION]'s Chorea, dementia, and anxiety. The 8/5/16 quarterly MDS assessment documented Resident #1 had modified independence for daily decision making. Resident #1's September 2016 MAR documented an order on 9/10/15 for 75 mg IM every 2 weeks [MEDICATION NAME] Docanoate for [MEDICAL CONDITION]'s Chorea. Resident #1's September 2016 Physician order [REDACTED]. The padded leg strap was observed throughout the survey attached around Resident #1's upper legs, and underneath and behind her wheelchair. The September 2016 MAR documented the IM [MEDICATION NAME] Docanoate was administered to Resident #1's right hip on 9/8/16. Resident #1's 9/14/16 Progress Note documented, Res(ident) noted to have 10 cm (by) 7 cm reddened area to R(ight) outer thigh (with) firm round center appears non tender to touch (no) bruising or open areas; (Physician) here to eval(uate) (Family Member) also present, states hematoma that should resolve n(o) n(ew) o(rders) re(ceive)d . Resident #1's Incident Report, dated 9/14/16, documented: On 9/14/16 Nurse noted a 10 cm (by) 7 cm oval area of redness with a firm lump in center on (Resident #1's) right upper thigh. (Resident #1) had no idea what had happened. (Resident #1) does move around a lot at times due to her [MEDICAL CONDITION]'s chorea. MAR revealed that (Resident #1) was given her [MEDICATION NAME] injection 9/12/16 on right hip .(Nurse) was a traveling nurse and has finished her contract with us. I was unable to contact her regarding the injection. Family and Hospice were notified. Hospice ordered warm packs to area. Area is resolving. The documentation did not include information ruling out Resident #1's leg restraint as a source of the injury. An undated and unsigned document provided by the facility on 12/1/16, documented, Interviewed (2 CNAs) regarding bump on thigh. They thought it could be from her attempting to throw herself out of her w/c or roll up to mat. Talked to (Nurse) who came in to assess res(ident). She thought it was an encapsulate from [MEDICATION NAME] IM . The facility's completed abuse investigations from June 2016 to November 2016 did not include documentation related to the above issue. On 12/1/16 at 8:35 am and 9:10 am, the Behavior Unit Manager said she interviewed two CNAs and a nurse, but did not have witness statements for them. She said Resident #1's leg restraint was ruled out as a source of the injury due to the location of the hematoma, which said was likely caused by the [MEDICATION NAME] injection. She reviewed the MAR and said the IM [MEDICATION NAME] was given to the right hip on 9/8/16, and not on 9/12/16, as the report documented. She said had she realized the discrepancies at the time of the investigation she would have investigated the incident as an injury of unknown origin to rule out abuse. On 12/1/16 at 9:25 am, the Administrator reviewed the investigation and said based on the information in the report, he could not determine the cause of the hematoma and it should have been investigated more thoroughly to rule out abuse. NOTIFICATION AND REMOVAL OF IMMEDIATE JEOPARDY: On 12/1/16 at 12:25 pm, the facility's Administrator was informed the deficient practices placed the identified residents, and other residents with injuries of unknown origin or who came into contact with the staff member accused of verbal abuse and intimidation, in Immediate Jeopardy of serious harm, impairment, or death. On 12/1/16 at 7:35 pm, the facility provided an acceptable immediate jeopardy removal plan to address findings at F225 and F226. Key elements of the plan included: * Thorough investigation of the incidents above related to Residents #1, #4, and #16. * Administrator and Corporate Compliance Nurse to begin review of grievance reports, accident and incident reports, and all other ancillary documents submitted over the last 60 days, with ongoing review during week-day IDT meeting, to identify any other potentially affected residents. * Individual and immediate in-service of all staff on the floor to assure they understood operation expectations to identify, report, investigate, and take corrective actions on all potential abuse, and conduct training with all staff prior to start of next shift. * Re-train all IDT staff members regarding properly identifying abuse allegations and examining contents of abuse allegation reports, accident/incident reports, occurrence reports, and grievances to determine what additional investigation is required and what state reporting requirements must be fulfilled. Implementation of the above actions was verified on-site and the facility informed on 12/1/16 at 8:20 pm, that the immediate jeopardy was removed.

Based on observation, staff interview and record review, it was determined the facility failed to ensure residents received nutritional interventions to prevent unplanned weight loss. This was true for 2 of 4 residents (#3 and #5) sampled for weight loss. As a result: a) Resident #5 was harmed when he experienced a severe unplanned weight loss without review and/or revision of nutritional and medication interventions, and b) Resident #3 had the potential for harm should he experience weight loss or [DIAGNOSES REDACTED] related to missed dining opportunities. Findings include: 1. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's weight on 8/17/16 was documented as 114 pounds, and his weight on 11/17/16, was documented as 104 pounds, a loss of 10 pounds, or 8.77% over a 3 month period. a. Resident #5's Nutritional Evaluation, dated 2/1/16, documented an ideal ideal body weight of 128-156 pounds. His weight at that time was 118 pounds, or a BMI of 19. Resident #5's weight dropped 11 pounds over the previous 30 days. The evaluation included a single recommendation of Smaller portions if regular portions are overwhelming. Weekly Nutritional Risk Review progress notes, from 8/2/16 to 11/22/16, were unclear as to what interventions were evaluated and whether new interventions were implemented. The Recommendations and New Interventions were unchanged from 9/12/16 to 11/22/16, and documented weekly weights and weekly reviews were to continue. Resident #5's nutritional care plan called for, High cal (calorie) ice cream with all meals. Resident #5's clinical record did not include documented intakes of high calorie ice cream. On 11/29/16 at 10:00 am, Resident #5 was observed eating toast and jelly. High calorie ice cream was not on his tray, and he was not offered high calorie ice cream with the meal. On 11/29/16 at 11:05 am, Resident #5 was observed with his midday meal of squash, potatoes and chicken. There were 4 beverages and a dessert in a bowl with cherries. High calorie ice cream was not on his tray, and he was not offered high calorie ice cream with the meal. On 11/30/16 at 9:00 am, Resident #5 was observed with 2 waffles, syrup, butter, and 4 beverages for breakfast. High calorie ice cream was not on his tray, and he was not offered high calorie ice cream with the meal. Resident #5's undated care plan documented, 120 cc K2 (supplement) with med pass TID. The MAR indicated [REDACTED]. The November 2016 MAR indicated [REDACTED]. Resident #5's care plan directed staff to, monitor food and fluid intake with meals. The meal monitor for November 2016 documented Resident #5 refused 40 meals - 21 breakfasts, 9 midday meals and 10 dinners. On 11/27/16, Resident #5 refused all 3 meals, in addition to breakfast on 11/28/16. Resident #5's undated care plan documented, TID snack requested per resident, % consumed, if refused, write why on back of sheet. (6 oz supplement). The November 2016 snack monitor documented Resident #5 refused snacks 33 of the 90 opportunities offered. Resident #5's physician-ordered medications with the potential to have an adverse impact on appetite included: [MEDICATION NAME] [MEDICATION NAME] [MEDICATION NAME] [MEDICATION NAME] [MEDICATION NAME] Klonopin [MEDICATION NAME] The nutrition care plan did not include documentation medications were considered as contributing to Resident #5's continued weight loss. Resident #5's Interdisciplinary Progress Notes, dated 9/9/16, documented his family and physician were to be notified monthly of weight losses and that Resident #5 would continue to be monitored. An Interdisciplinary Progress Note, dated 9/15/16, documented Resident #5 continued to have poor intake and weight loss. The note documented his physician and family were aware the weight loss may be unavoidable. An Interdisciplinary Progress Note, dated 10/10/16, documented Resident #5 had a Stage II pressure ulcer, and his meal intake was poor. Resident #5's weight loss was documented as possibly unavoidable. No new interventions were noted, and the Care Plan was not revised. An Interdisciplinary Progress Note, dated 11/9/16, documented Resident #5 was monitored for weight loss, and received a mechanical soft diet, with 1-2 finger foods, snacks TID, high calorie ice cream with each meal and K2 120 cc TID with medications. The care plan did not address Resident #5's noted refusals of meals, snacks, or supplements. On 11/30/16 at 9:40 am, the Dietary Manager stated each resident's diet card was reviewed with each meal. She stated diet cards included supplements, which for Resident #5 included high calorie ice cream. The Dietary Manager stated each meal was prepared according to the resident's diet card. She stated if a resident was asleep for a meal, or requested a certain item for that meal, then the new meal tray would be set up and would not include supplements or high calorie ice cream. She stated the BCP had a refrigerator/freezer, and should maintain a supply of high calorie ice cream for those occasions. On 12/1/16 at 9:50 am, the Behavioral Unit Manager stated Resident #5's care plan should have been revised and updated to include interventions related to his refusals of meals, include dates when each intervention was initiated, and revision dates. The Behavioral Unit Manager stated care plans were reviewed and revised by the interdisciplinary team, not the nursing staff of the BCP, and that she did not see documentation medications were assessed as a factor with Resident #5's weight loss. Additional information provided by the facility on 12/7/16, documented Reviewed resident's care plan twice in the month of his wt (weight) loss. No updates were necessary due to everything already in place on care plan. Resident #5 experienced weight loss of greater than 8.7% over a period of 3 months. The care plan did not address medications that may have contributed to his weight loss. Additionally, his care plan was not revised to include interventions for refusals, and interventions were not fully implemented as ordered. 2. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #3's weight on admission was documented as 156 pounds. Resident #3's Care Plan Flow Sheet documented he did not receive 18 meals over the 21 day period since his admission, which indicated 28% of meals. On 12/1/16 at 2:13 pm, the Behavioral Unit Manager reviewed Resident #3's record and stated she was not aware of the frequency of his missed meals.

Based on observation, staff interview and record review, it was determined the facility failed to ensure residents with urinary catheters received necessary care and services to prevent urinary tract infections. This was true for 2 of 2 (#s 1 & 2) sampled residents reviewed for urinary catheters. Resident #2 was harmed when she acquired 3 urinary tract infections and required hospitalization for urosepsis. Resident #1 had a urinary catheter in place with no correlating care plan or documentation of catheter care, which created the potential for urinary tract infections or other complications associated with indwelling catheter use. Findings included: The Suprapubic Catheter Care Policy and Procedure, revised on 10/10, documented, "...Documentation. The following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual(s) who performed the procedure. 3. All assessment data obtained during the procedure. 4. How the resident tolerated the procedure. 5. If the resident refused the procedure, the reason(s) why and the intervention taken. 6. Results of skin assessment around the stoma site. 7. Character of urine such as color...and odor. 8. Any problems or complaints made by the resident during the procedure. 9. The signature and title of the person recording the data..." 1. Resident #2 was readmitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The most recent significant change MDS assessment, dated 9/23/14, documented Resident #2 had moderate cognitive impairment with a BIMS of 12, had an indwelling catheter and required total assistance of 2 people for toilet use. Resident #2's ADL Care Plan documented the Toileting Plan was discontinued on 5/12/14 and a handwritten revision documented, "Suprapubic cath(eter) placed - empty (and) record cc's (cubic centimeters). Cath care per protocol." Resident #2's Care Plan, dated 9/20/14, documented the problem of suprapubic catheter with potential for UTI's (Urinary Tract Infections) related to MS, history of urosepsis and [MEDICAL CONDITION] bladder. Interventions included monitoring for signs and symptoms of UTI and urosepsis, and suprapubic catheter care every shift. The July through October 2014 Care Plan Flow Sheets for Resident #2 documented suprapubic catheter care was to occur every shift. This was on the flow sheet as, "Info Only," and did not require documentation. The Flow Sheets included the statement, "I HAVE GIVEN CARE ACCORDING TO ADL CARE PLAN...," which was documented with initials every shift. The following documentation was gathered from Resident #2's Physician's Telephone Orders (PO), Care Plan (CP), Treatment Administration Record (TAR), Urology Reports (UR), History and Physical (H&P) and Interdisciplinary Progress Notes (PN): * 3/25/14 (UR) - "[MEDICAL CONDITION]: Patient complains of dysuria...Plan: Patient with advanced [MEDICAL CONDITION] causing [MEDICAL CONDITION] bladder and probable [MEDICAL CONDITION]. This could very well be leading to her recurrent urinary tract infections. I explained to the patient that the only effective treatment for [REDACTED]. * 5/12/14 (CP) - Handwritten revision, "Suprapubic cath(eter) placed - empty (and) record cc's (cubic centimeters). Cath care per protocol;" * 5/12/14 (TAR) - "Follow Foley Cath Care sheet provided;" (Note: Documentation with initials was not required on the TAR) * 5/28/14 (PN) - "...Catheter patent draining dark urine...;" (Note: TAR for June 2014 did not contain documentation of catheter care.) * 6/6/14 (PO) - "[MEDICATION NAME] 500 mg PO TID x 7 days;" * 6/13/14 (PN) - "...dark amber blood tinged urine in cath bag...;" * 6/13/14 (PO) - "Reculture urine. Continue [MEDICATION NAME] for 5 more days;" * 6/15/14 (PO) - "Amox(icillin) 250 mg po q (every) 8 (hours) until [MEDICATION NAME] available;" * 6/24/14 (PN) - "...clarification of abx (antibiotics) orders. Explained resident is asymptomatic...dark amber/red urine (with) visible sediment...;" * 6/24/14 (PO) - "[MEDICATION NAME] 875 mg PO BID x 7 days;" (Note: TAR for July and August 2014 did not contain documentation of catheter care.) * 8/24/14 (PN) - "...Resident was (with) s/sx of UTI i.e. (change) in character of urine, worsening of mental/functional status. Dip performed (with) results of [MEDICATION NAME] (and) blood off the chart...PCP notified. NO (New orders) received...;" * 8/24/14 (PO) - "[MEDICATION NAME] 1 gm IM Daily x 5 days. Urine C&S (Culture & Sensitivity);" * 9/11/14 (TAR) - "Assess SP insertion site Q (Every) PM - Cleanse;" (Note: On 9/16/14 the TAR had no initials documenting the catheter care had been performed.) * 9/16/14 (PN) - "Resident unable to respond to questions at this time, very little P.O intake noted. (No) calling out from room, (no) movement noted...family called...;" * 9/16/14 (PN) - "...agreed to notify MD of condition change...;" * 9/17/14 (PN) - "(Resident's name) is nonverbal, (increased) lethargy...urine = hematuria (at) this time;" * 9/17/14 (PN) - "...in bed eyes half closed, unable to swallow am meds, not able to make needs known verbally or (with) cue cards...cath (with) dark orange urine in bag (and) tubing, PCP called left message (with) update, return call (with) order to send to ER...;" * 9/17/14 (PO) - "Admit to (local hospital) for tx (treatment) of Urosepsis;" * 9/17/14 (PN) - "(Local hospital) reports Resident admitted for eval and treat of suspected urosepsis;" and, 9/17/14 (H&P) - "History of Present Illness:...The patient transferred to the emergency room for evaluation due to decreased mental status...Assessment and Plan:...3. Suspect acute exacerbation of bladder infection, given catheter source..." (Note: On 9/27 through 9/29/14 the TAR had no initials documenting the catheter care had been performed. In addition, the October 2014 TAR did not contain documentation of catheter care.) Resident #2 was observed to have a urinary catheter in place on 10/21/14, 10/22/14 and throughout the survey process. On 10/23/14 at 9:20 a.m., LN #5 was interviewed about Resident #2's multiple urinary tract infections and catheter management. The LN said the resident showed symptoms of UTI's with, "Slurred speech, a lot more confused," and the temperature would spike. "The Aides" were responsible for catheter care every shift and the nurses would oversee the care that was performed. When asked where catheter care was documented, the LN stated, "I'm sure it's on their ADL flow sheets. I know it's on the TAR." After reviewing the ADL flow sheets and TAR, the LN stated, "That needs to be changed, can't believe it isn't on the TAR. You would think medical records put it on there. That will definitely be changed." LN #5 added when the CNA's initial the statement of giving care according to the ADL Care Plan, catheter care was part of ADL care. The LN stated, "I can tell you it's being done," and Resident #2 got the suprapubic catheter for the recurrent UTI's because the bladder was not emptying. On 10/23/14 at 10:55 a.m., with the Administrator and Corporate Compliance Nurse (CCN) present, LN #5 told the surveyor she had "already fixed the TAR and CNA Flow sheets." When asked why catheter care was added to the TAR in September but not the previous months, the LN stated, "I wouldn't have written that on there if it was already on the TAR." The RNC looked through the TARs from June through September 11 2014 and October 2014 and did not find catheter care documentation for Resident #2. On 10/23/14 at 2:25 p.m., the Administrator, with LN #5 and CCN present, said if catheter care was on the ADL Care Plan that the blanket statement meant it was performed, and it was not productive for the CNA's to chart on each and every item on the Care Plan. LN #5 stated the nurse who wrote the catheter care on the TAR in May 2014 did not make it for people to document or sign it had been performed. The Administrator stated, "Per our policy, the charting is not adequate." On 10/23/14 at 4:10 p.m., the Administrator, DON and CCN were informed of the concerns with infections and suprapubic catheter care. The DON acknowledged the concern and stated, "It should have been on there (TAR)." On 10/27/14, further documentation was provided by the facility for Resident #2, however, it did not resolve the issue. 2. Resident #1 was readmitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The facility's Catheter Care policy, revised on October 2010, documented: "The following information should be recorded in the resident's medical record: 1. The date and time that catheter care was given. 2. The name and title of the individual(s) giving the catheter care. 3. All assessment data obtained when giving catheter care..." The resident's Physician's Telephone Orders, dated 10/3/14, documented staff was to place a foley catheter for [MEDICAL CONDITION] until a surgical consult appointment was completed. The resident's Interdisciplinary Progress Notes (IPN) documented a foley catheter was placed on 10/3/14. The resident's IPN documented from 10/3 to 10/20/14, the catheter was intact with a description of the urine color, however the notes did not document catheter care was performed. The resident's ADL or Urinary care plans did not document the resident had a foley catheter in place and did not document who would complete catheter care. The resident's October 2014 TAR did not document the resident had a foley catheter, did not include when to change the catheter bag and did not include an area to document catheter care. On 10/20/14 at 1:33 PM and throughout the survey, the resident was observed to have a catheter. On 10/22/14 at 3:10 PM, the Behavioral Care Program Coordinator was interviewed regarding the catheter issues. When asked to review the care plan to see where the catheter was addressed, she stated, "There's nothing in here I can see." When asked if information was on the TAR or MAR indicated [REDACTED]." On 10/23/14 at 3:50 PM, the Administrator and DON were informed of the catheter issues. On 10/27/14 at 4:35 PM, the facility faxed additional information regarding the catheter issues, however the information did not resolve the concerns.

Based on record review and staff interview, it was determined the facility did not ensure 2 of 6 (#'s 1 & 6) sampled residents for falls was provided adequate supervision. Resident #1 was harmed when staff failed to provide one on one supervision as directed by the care plan and the resident stood unattended and fell , which caused a left hip fracture and required surgical intervention. Additionally, the facility failed to provide adequate supervision when Resident #6 experienced four falls. Finding included: 1. Resident #1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's 5/9/14 quarterly MDS assessment, documented the resident: *Was severely cognitively impaired, BIMs = 1; *Had signs of inattention and disorganized thinking; *Required extensive assistance with two staff to transfer; and, *Not steady, when moving from seated to standing position. The resident's Fall Risk Evaluation, dated 5/9/14, documented the resident was a high risk for falls. The resident's Fall care plan, dated 2/18/14, documented the resident was at a high risk for falls related to a right hip fracture, dementia, osteoporosis and paranoia. Interventions included, "If awake and restless at night when roommate is sleeping, bring to common area and provide an activity or 1:1 (one on one) time." The resident's ADL care plan, dated 2/18/14, documented an intervention of, "Do not leave unattended in common area. Provide 1:1 time as needed for safety and behaviors." A facility "Fall Scene Investigation", dated 5/26/14, indicated the resident fell on [DATE] at 10:25 PM in front of the nurses station. The investigation documented the resident was confused and wanted to walk prior to the fall. The facility identified the root cause as, "Possibly hip fx (fracture) then she fell ." A staff statement attached to the investigation, dated 5/26/14 regarding the fall, documented by CNA #3: "I was sitting at the nurses station and I was getting ready to sign the wheelchair paper when I heard (Resident #1's) alarm, her pull-tab alarm go off. I looked up and I seen (sic) her standing up in front of her wheelchair. (CNA #4) told me to go and have her sit down, so I got up and was going to (Resident #1) to have her sit back down, however by the time or before I even got to her, she had fallen. I was right at the edge of the nurses station when she went down...She had already stood up once, because she wanted to walk around. We got her to sit back down, and told her that as soon as we were done, that (CNA #4) was or would take her on a walk. She was happy with that and she sat right back down. And after I signed the wheelchair paper, I was going to get the alarm checklist and take care of that." A staff statement attached to the investigation, dated 5/26/14 regarding the fall, documented by CNA #4: "(Resident #1) was in her wheel chair with alarm pull tab on. She had stood up once I (CNA #4) had sat her back down, told her we would walk her when I got my paperwork done. (CNA #3) had just came to get alarm check list and (Resident #1) had stood up again and before (CNA #3) or myself could get around the station she had stood and fell it was 10:25 PM (sic)." A "Memorandum For Record" attached to investigation, dated 6/4/14, documented: "CIRCUMSTANCES SURROUNDING ACCIDENT: resident was sitting in her w/c (wheelchair) at the nurse's station and had been attempting to stand AEB (as evidenced by) alarm sounding when she tried. She was told at least once to remain sitting and they would take her for a walk when they finished up some paperwork on the other side of the nurse's station. She stood from her w/c and before staff could get around the nurse's station to reach her, she fell to the floor." The Conclusion documented, "given resident's prominent degenerative changes in her spine and hips, this fall could have happened because of osteoporosis. Never the less, she broke her hip because she stood and before staff could reach her she fell ." The "Plan" documented: "1. Staff education regarding residents needs being met before paperwork. 2. Continue in the behavior program with increased staffing. 3. Continuing staff in-service's (sic) on meeting the needs of the cognitively impaired..." The resident's Interdisciplinary Progress Notes documented the resident was transferred to a local hospital on [DATE] at 10:53 PM via ambulance. A local hospital record, dated 5/27/14, documented the resident was admitted to the emergency room , "...with left hip fracture after a ground-level fall." The hip fracture required surgical repair. On 10/22/14 at 3:10 PM, the Behavior Care Program Coordinator was interviewed regarding the incident. She reviewed the investigation and staff statements. When asked if staff chose to complete paperwork over resident care she stated, "I don't discount that." She also said because of the incident, staff was re-educated to put resident care before paperwork. When asked about the Memorandum conclusion, she stated, "I still think it could have been osteoporosis." When asked if the resident's physician supported this theory, she stated, "No he didn't." Note: The resident's physician progress notes [REDACTED]. On 10/23/14 at 10:30 AM, the Administrator and Corporate Compliance Nurse asked the surveyor to review the fall incident with them. During the discussion, the Administrator stated regarding the incident, "Staff made an error and could have done something different." The facility did not ensure they kept the resident safe when she stood twice without assistance and fell on the second attempt, even though she was a high fall risk, was unable to maintain balance, was severely cognitively impaired with inattention, and staff chose to complete paperwork over caring for the resident's one on one needs as directed by the care plan. On 10/23/14 at 3:50 PM, the Administrator and DON were informed of the issues. On 10/27/14 at 4:35 PM, the facility faxed additional information regarding the incident, however the information did not resolve the concerns. 2. Resident #6 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's most recent quarterly MDS assessment, dated 7/11/14, documented: *The resident was assessed by the facility to have severely impaired decision making abilities, and *Needed extensive assistance of 2 + persons for bed mobility, transfers, walk in room and corridor, locomotion on unit and toilet use. On 8/6/14 a physician progress notes [REDACTED]. I have seen a change markedly in the last 6 months. She is not getting up and walking around as she used to...she does smile occasionally but is not attempting to communicate with me, as in the past." Record review documented Resident #6 had four falls between 8/15/14 and 9/12/14: a. The resident's first fall occurred, on 8/15/14 at 9:00 PM. She was propped up in bed after coffee ground emesis were discovered at 5:10 PM. The nursing progress notes for 8/15/14 Days documented, "Resident alert, active moving self about in W/C to D/R (dining room)." The Incident Report, dated 8/15/14, documented, "Res(ident) has continual movements and will now be propped towards wall." The new intervention to prevent falls documented, "Angle towards wall, already on Falling Star Program." NOTE: The resident was found on the floor 4 hours after being propped up in bed. b. The resident's second fall occurred, on 8/24/14 at 10:15 PM, when the resident was found on the floor beside her bed. The Fall Scene Investigation Report, dated 8/24/14, documented the fall was unwitnessed and the resident was found when staff looked in the resident's room and saw her "in a fetal position laying on her left arm, not moving, just laying there." The Accident Report CNA/NA, which was not signed or dated, for the 8/24/14 fall documented, "(Resident #6's) alarm went off and we went running, saw (Resident #6) on the floor, looked like she rolled off bed." The new intervention to prevent falls documented, "Continue pull tab and motion alarms, continue 15 minute visual checks, and consider appropriateness of concave mattress." The medical record did not contain evidence of increased supervision. No documentation of 15 minute checks was found. c. The resident's third fall occurred, on 8/28/14 at 5:12 PM, as a result of being pushed in her wheelchair down the hallway. The nursing progress notes, before the fall, documented: *No time given, "(Resident #6) is very anxious, awake, grabbing at things, her left side of face appears to be swollen..." *2:30 PM, "Res(ident) with watery diarrhea, put on contact precautions to no (sic) intestinal virus." After the fall, the nursing progress notes documented: *9:30 PM, "At 5:12 PM resident was being transferred or pushed by W/C out of room and suddenly planted feet and lunged forward. Staff pushing resident was able to slow impact by grabbing resident's shirt but resident fell forward on to face, resulting in 3 cm abrasion with contusion to forehead...Resident maintains a forward leaning posture whenever up in W/C." The Fall Scene Investigation Report, dated 8/28/14, documented the resident was, "Reaching forward and lost balance...agitated r/t (related to) pending room change and activity redirection and lunged from chair..." A Staff Statement, dated 8/28/14 at 5:15 PM, documented, "I was coming down the hall just after a med(ication) pass when I saw (Resident #6) being wheeled out of her room to be moved for isolation precautions, just after she passed the door threshold she bent forward very quickly reaching towards the ground as she is prone to do. She overreached after propelling herself completely out of the W/C landing on her forehead and knees." The new intervention to prevent falls documented, "Increased staff supervision, treat for anxiety, request therapy consult for possible geri-chair related to forward bearing posture. Therapy screened and cushion - chair appropriate." Additionally, the root cause section of the Fall Scene Investigation Report documented a contributing factor of the fall was agitation. However, the resident's fall care plan had not been updated to address how staff would respond if the resident was agitated while in the W/C. d. The resident's fourth fall occurred, on 9/12/14 at 8:28 PM, when the resident rolled out of bed and was found on the floor. A nursing progress note, dated 9/12/14 at 9:30 PM, documented, "Res(ident) found at 8:28 PM on floor by bed." An Accident Report, dated 9/12/14, documented, "I heard a thump, then alarms and found the resident laying on the floor on her right side. She rolled out of bed." A Fall Scene Investigation Report, dated 9/12/14, documented, "Res(ident) rolled OOB (out of bed) and hit occiput (back part of the head) and possibly right elbow on side table." A Resident Incident Report, dated 9/12/14, documented, "...Res(ident) was on floor next to bed, supine, skin tear to right lateral elbow and small laceration to right occiput most likely from side table." The new intervention to prevent falls documented, "Side table moved to end of bed, pillows to bolster resident in place, and foam surround air mattress with bolster." On 10/22/14 at 5:15 PM, the DON was interviewed regarding the four falls the resident experienced from 8/15/14 to 9/12/14. When asked for documentation of increased supervision, the DON stated, "We don't have documentation for 15 minute checks because everyone is checked 15-30 minutes. If they are on the Falling Star Program, the resident is checked every 15 minutes and this resident is on the Falling Star Program." The DON pointed to The Fall Scene Investigation Reports for each fall and the interventions placed to prevent future falls. The facility failed to ensure Resident #6 was free from falls and could not provide documentation of increased supervision to keep the resident from falling even though they knew she was a high fall risk and was severely cognitively impaired.

Based on record review, and staff interview, it was determined the facility failed to ensure residents who entered the facility without pressure sores did not develop pressure sores. This was true for 2 of 4 (#1 & #12) sampled residents reviewed for pressure sores. The facility failed to assess and prevent a stage III pressure ulcer from forming on Resident #1's coccyx, causing harm and put the resident at risk for pain and infection. The facility also failed to prevent a stage II pressure ulcer to Resident #12's sacrum. Findings included: 1. Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #1's admission MDS dated [DATE], coded: * did not have pressure sores, * had Moisture Associated Skin Damage (MASD), * required two person assist with bed mobility, * frequently incontinent of bladder and bowel, * moderately cognitively impaired. The Resident's Interdisciplinary Progress Notes dated 5/20/13 by an LN documented, "C.N.A. called me to res(ident) room to observe an open sore to sacrum. This sore is 1.5 cm x (by) 1.5 cm x 4 mill(imeter)." An LN note on 5/21/13, documented, "Stage II pressure ulcer observed @ (at) coccyx, approx(imately) dime size open lesion. Skin surrounding site (with) blanching redness, new foam dressing applied (with) [MEDICATION NAME] @ wound edges, resident tolerated procedure well, two person max(imum) assist (with) repositioning and bed to chair transfers. Continue to monitor." Note: There were no progress notes for five days prior to 5/20/13, when the pressure sore was discovered. The Resident's Wound Care Flow Sheet, documented in part the following: "Site #2 Acquired here, 5/22/13-P.U. (pressure ulcer) Stage III, coccyx, .9 x 1 cm x .4 cm, color- pink, tissue-80/20% slough/pink, pain-0, 5/29/13-.8 x .8 x .2 cm, 100% covered (with) tan slough, 6/7/13-.8 x .4 x .2 cm, 50% pink/50% tan slough, 6/14/13-.5 x .5 x .2 cm, 100% pink, granulation, 6/21/13-.5 x .5 x .1 cm, pink, 7/10/13-.3 x .3 x .1 cm, pink, 7/15/13-Resolving Stage III, .2 x .2 x .1 cm, pink, 7/22/13-.1 x .1 x .1 cm, pink, 7/24/13-Resolved." The Resident's Pressure Sores/Skin Care plan dated 5/3/13, documented: "Treat as high risk, Turn every 2 hours and PRN side-side, Float heels, Alt(ernating) air mattress, [MEDICATION NAME] or [MEDICATION NAME] to inner buttocks as needed, Liner open as tolerated." The Resident's High Risk Pressure Relief Interventions (ADL Care Plan) dated 5/8/13, documented: "Pressure relief cushion in chair/wheelchair or geri chair, Barrier cream with each incontinent episode, Use [MEDICATION NAME]/[MEDICATION NAME] to the buttocks MASD." The Resident's May 2013 TAR documented on 5/5/13, "Bilat(eral) R (right) buttock-cleaner (with) pericare apply Calmosetine prn & BID." The TAR also contained four out of six opportunities when [MEDICATION NAME] should have been applied but was not documented as being applied between 5/16/13 to 5/18/13. The Resident's Physician's Telephone Orders dated 5/28/13, documented, "Pressure ulcer to coccyx-Stage III, 1) Vit(amin) C 250 mg PO daily until resolved, 2) Zinc 220 mg PO daily x 30 days, 3) Santyl [MEDICATION NAME] to wound bed daily until 0 (no) slough present." On 8/14/13 at 11:45 AM, the Wound Nurse was interviewed regarding Resident #1's Stage III pressure ulcer and she stated the pressure ulcer went from, "nothing to a III." When asked how this happened she stated, "I don't know that...I have just as much questions (sic) about that." She said she had interviewed C.N.A. and nursing staff on how the ulcer went from red to open, but said they did not have the answers either. She stated, "did the [MEDICATION NAME] get down to skin?" When asked to clarify this statement, she said she questioned if the pericare was adequate enough in order for the the barrier cream to be effective. Note: The resident was incontinent of bowel and bladder and the [MEDICATION NAME] was in place to treat excoriation due to MASD and to prevent pressure ulcers. On 8/15/13 at 6:40 PM the Administrator, Administrator in Waiting, DON, Corporate Nurse, Resident Services, and Behavior Care Manager were informed of the issue. On 8/19/13 the facility faxed additional information regarding Resident #1's situation. The additional information contained the following statement, "At the time the pressure ulcer was discovered to the coccyx, she was being treated for [REDACTED]. The bilateral buttocks were excoriated with erosion secondary to incontinence of bowel and bladder; the treatment was [MEDICATION NAME] ointment, which is a thick pink ointment. It was to be applied in a thin layer after each incontinent episode. This may have contributed to not visualizing the affected tissue turning red prior to opening." The facility failed to prevent a Stage III pressure sore due to failing to assess and differentiate between red skin and pink barrier cream, causing harm to the resident. 2. Resident #12 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #12's quarterly MDS dated [DATE], coded: * did not have pressure sores, * required one person assist with bed mobility, * frequently incontinent of bladder and bowel, * severely cognitively impaired. The Resident's Interdisciplinary Progress Notes, documented on 7/23/13, "Stage II P.U. found to sacrum-dres(sin)g of Exuderm thin placed...PUCP (pressure ulcer care plan) initiated...Braden scale =#16=@ risk-will tx (treat) as High. ADL CP updated to get oob (out of bed) for meals only, side lying position (with) Q (every) 1-2 (hour) turning. Plus 2 TID (with) med pass for added protein to aid in wound healing. Risk factors include: B&B (bowel and bladder) incontinence, freq(uent) resistance to cares, [MEDICAL CONDITION], Alz(heimer's) dementia, [MEDICAL CONDITION], aggressions, DM (diabetic mellitus)." The Interdisciplinary Progress Notes document in part the following: "7/25/13-Wound bed pink, dry. Edges clean. Surrounding tissue intact, blanching, 7/26/13-Tissue surrounding wound pink & blanches, 7/27/13-Surrounding tissue pink & blanches." Note: Similar notes as above are found on 7/28, 7/29, 7/30, 7/31, 8/1, 8/2, 8/3, and 8/4/13. The resident was sent to a local hospital on [DATE] for two days for an unrelated non-responsive incident. "8/7/13-P.U. to sacrum-now unstageable (secondary to) 95% covered (with) grey/black moist tissue, red bleeding tissue pinpoint in center. Surrounding tissue is irritated, red dry, and blanching-appears to be from old drsg (dressing). Wound bed cleaned, new thin [MEDICATION NAME] placed. Will obtain order for Collegen gel to debrided necrotic tissue...Continue to tx as High, 8/8/13-Surrounding tissue red, dry. [MEDICATION NAME] skin prep to edges & surrounding tissue, Collagen hydrogel placed on necrotic tissue for debrided. Covered (with) adhesive foam. Added to PUCP to be last up & first down-up for meals only-as tolerated, 8/12/13-P.U. to sacrum originally found as Stage II-while @ (local hospital) P.U. worsened and upon return the wound bed was covered (with) grey/black moist eschar = unstageable. Tx of Collagen gel to debride successful as (no) eschar present today. Wound bed 100% pink, moist (with no) maceration to edges. Surrounding tissue (with) some blanching redness." The Resident's Wound Care Flow Sheet, documented in part: "7/23/13-Stage II, L(ength) .8 W(idth) .5 D(epth) .2 (cm), 8/5/13-Resident @ (local hospital), 8/12/13-Stage III, L 1.8 W .7 D .2 (cm)." The Resident's Potential for Pressure Ulcer, Impairment of Skin Integrity Care Plan dated 11/16/12, documented in part the following interventions: *Pressure relief mattress, *Observe for any skin impairment with giving care, *Gel cushion in W/C. The Resident's Potential for Pressure Ulcer, Impairment of Skin Integrity Care Plan dated 7/25/13, documented in part the following additional interventions: *Pressure reducing Gel cushion in W/C, *Turn q 1-2 (hours) side to side. Use pillow behind back for side lying position. The Resident's Physician's Telephone Orders dated 7/23/13, documented, "Exuderm thin-[MEDICATION NAME] drsg to P.U. on sacrum. (Check every) 3 days & PRN. K2 Plus (supplement) TID (with) med pass 90-120 cc-aid in wound healing." On 8/15/13 at 12:15 PM, the Wound Nurse was interviewed regarding Resident #12's Stage II pressure sore. When asked how the resident acquired the sore, she stated, "I don't know...She was low risk...It's a never event." When asked to clarify what she meant by a 'never event', she stated, "It should not have happened." On 8/15/13 at 6:40 PM the Administrator, Administrator in Waiting, DON, Corporate Nurse, Resident Services, and Behavior Care Manager were informed of the issue. On 8/19/13 the facility faxed additional information regarding Resident #12's situation. The additional information contained the following statement, "She is often combative during and resistant to cares." The resident's Care Plan did not contain a section which identified the resident displayed resistance to cares. The Resident's Interdisciplinary Progress Notes from 7/11/13 to 7/23/13 and Social Services Progress notes 4/20/13 to 7/23/13 did not mention resistance to cares or interventions tried. Resident #12's Psychopharmacologic Behavior Monitor Sheet under the section entitled, "Refuses position changes" from 7/1/13 to 7/23/13, documented the resident had no refusals for the AM shift, two refusals for the PM shift, and three refusals during the night shift.

Based on observation, record review, and staff interviews, it was determined the facility failed to ensure residents without pressure ulcers (PUs) did not develop pressure ulcers. This was true for 1 of 4 residents (#18) reviewed for pressure ulcers. Failure to recognize pressure as a contributing factor related to a left thumb joint skin problem, to notify the physician timely and to revise the care plan to include the left thumb joint skin problem, created the potential for more than minimal harm should the facility fail to implement appropriate preventive measures related to the resident's risks, level and nature of risk, or presence of PUs. Findings included: Note: The facility was cited at F 314, Pressure Ulcers, during the annual survey conducted 8/16/13. Resident #18 was most recently readmitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's PU CAA, dated 5/31/13, included the following documentation: * "Treatments and other factors that cause complications or increase risk(:) Functional limitation in range of motion...limited use of his left shoulder and arm..." * Analysis of Findings - "PROBLEM: potential for (PU). CAUSES/CONTRIBUTING FACTORS: ...DJD ([MEDICAL CONDITION] joint disease) with pain...chronic [MEDICAL CONDITION](.) RISK FOR: skin breakdown/pressure ulcer...Current Care plan reviewed...no changes...assist in minimizing the potential for (PU) as per cause/contributing factors listed...and to lessen or prevent the risk factors listed...if (PU) do occur with an overall goal of prevention and effective treatment of [REDACTED]. The resident's most recent quarterly MDS assessment, dated 8/23/13, coded, in part: * Severe cognitive impairment, with a BIMS score of 4; * Rejection of cares 4-6 days during the look back period, but less than daily; * Extensive assist of 2 or more people for most activities of daily living; * Functional limitation in range of motion in both lower extremities; * At risk for pressure ulcers (PU); * No unhealed PU/venous or arterial ulcers/other ulcers, wounds, skin problems/other skin problems (included moisture associated skin damage); and, * Application of ointments/medications other than to feet. Review of the facility's Weekly Skin Impairment List (WSIL) audits, dated 9/16/13, 9/19/13, 9/25/13, 10/3/13, 10/10/13, 10/17/13, 10/24/13, and 11/4/13 documented an open area between the resident's left thumb and 2nd finger initially; then on 10/17, an open area on the left inner thumb at the joint. The WSIL audits included resident names, the skin problem, location, stage, and treatment for [REDACTED]. The audits also included an area for comments. The WSIL audits noted the following skin problems for Resident #18: * 9/16 - Skin Problem: "Open area caused by contractions." Location: "L (left) hand, between thumb & 2nd finger." Stage: "n/a (not applicable)." Treatment, "Daily cleanse w(with)/Vashe solution, gauze to protect and eliminate skin-to-skin contact. Inflatable posey placed 9/13/13..." Healing? "Yes." Care plan current? "Yes." Comments: "Fungal component-using antifungal powder after each cleanse." * 9/19 and 9/25 - Essentially the same as above, except: "Comments: No open areas at this time. Will continue w/daily cleanse and inflatable posey." * 10/3 and 10/10 - Essentially the same as above. * 10/17 - A new skin problem was identified as "Open area caused by contractions(;) Location: Left thumb at joint, inner aspect(;) Stage: n/a(;) Treatment Vashe cleanse, cover w/gauze/ Place inflatable Posey(;) Healing? New(;) Care Plan Current? Yes" and, "Comments: Daily assessment with placement of posey." * 10/24 - Same as above, except: "Healing? No" and "Comments: Daily assessment with placement of posey by LN (licensed nurse)." * 11/4/13 - Same as above, except: "Treatment Vashe cleanse, cover w/gauze. Place inflatable Posey. BID (2 times a day)" and "Comments: Daily assessment with placement of posey by LN. Will discuss with IDT (interdisciplinary team)...next week." The care plan in the resident's chart directed the reader to the Skin Impairment/Pressure Ulcer Care Plan folder at the nurses' station. The resident's skin/PU care plan located at the nurses' station and "Printed: 6/5/13," included the following documentation: * "Problem: 10 Skin Impairment/Pressure Ulcer Care Plan-See Skin Care Folder at Nursing Station. * Related to: ...OA/DJD ([MEDICAL CONDITION] joint disease)...chronic stasis [MEDICAL CONDITION], chronic pruritis, Hx (history) of non compliance to pressure relief measures. * Exhibited by: ...Pain and contractures of knees/impaired mobility...Confusion and behaviors/resistant to cares... * Interventions: Frequency/Duration Resolved Disc(cipline) 1 See ADL care plan for individual interventions 2 Please monitor & implement for the following pressure ulcer prevention interventions daily on your shift: NDE (nights, days, evenings)...8...Pad bony prominences with pillows...11 Contact [MEDICAL CONDITION] bilateral arms with treatment prn (as needed); see TAR- (refused several attempts of consult appointments with dermatologist)..." This care plan did not include anything about the open area at the left inner thumb joint. On 11/6/13 at 3:20 p.m., the facility's wound nurse (WN), was interviewed. When asked about the open area on the resident's left thumb joint, the WN stated, "It started as a fungal infection in the palm that resolved and moved to the web between the thumb and forefinger." Then the WN stated, "It was not the palm. It was the webbing." When asked if a doctor had assessed the area, the WN stated, "I don't know if (physician's name) ever looked at it." When asked who determined it was a fungal infection, the WN stated, "Me." The WN informed the surveyor that the physician had assessed the resident's left thumb that day. The WN stated, "He thinks the splint is causing pressure" and that the physician discontinued the splint that day. When asked if she had considered pressure as the cause, or a contributing factor to the resident's left thumb joint skin problem, the WN stated, "No." When asked about the care plan for the left thumb joint skin problem, the WN stated that she would have completed a temporary care plan and the temporary care plan would have "gone away" when the problem resolved; or, it would have been added to the on-going care plan. When asked if the problem had gone away, the WN stated, "No." The WN reviewed the resident's skin/PU care plan and confirmed that the left thumb joint skin problem was not included in the care plan at the nurses' station or in the resident's chart. The WN stated that the skin/PU care plan "was for pressure ulcers only." On 11/6/13 at 4:05 p.m., 2 surveyors accompanied the WN to the resident's room. The resident's left fingers were observed to be contracted with the inner aspect of the distal interphalangeal (DIP) joint of the thumb (1st finger) pressed against the side of medial interphalangeal (MIP) joint of the 3rd finger. When the WN opened the resident's left hand, an intact blackish circular area, about 1.5 centimeters (cm) in diameter, was observed on the inner aspect of the DIP joint of the thumb. On 11/7/13 at 8:35 a.m., the surveyor accompanied the WN to the charting room where the WN looked for a temporary skin care plan for Resident #18. However, she did not find one. When asked how the thumb joint skin problem was tracked, or documented, the WN said, "In nurses' notes and the TAR." The WN stated she would use wound tracking sheets, "For the ones that are more severe." When asked if any wound tracking sheets were used regarding the resident's left thumb joint skin problem, the WN stated, "No." Interdisciplinary Progress Notes (IPN) dated 6/26/13 through 11/6/13 documented: * 7/9/13 "NSG (nursing) ...aides reported open to the resident's left hand. * 7/10 - "O.T. (occupational therapist) "...unable to open his fingers or move his wrist...Do not recommend O.T...Spoke to wound RN (registered nurse) and we agreed daily skin care, dressing on his wound changed daily, and a soft splint in his hand to prevent further fingernail damage to the palmer surface of his left hand." * 7/10 - "Wound care: impairment to (L) (left) hand (at) area between thumb and index finger: open area...(without) drng (drainage( (without) S/S (signs/symptoms) of infection... * 7/11 at 10:45 a.m. - "NSG ...Web of thumb/forefinger (with) open area...Wound margin distinct, (without) maceration...posey soft hand splint placed... * 7/16 at 10:45 a.m. - "NSG ...dressing in place to left hand, superficial abrasion noted superior to dressing... * 7/17 "Wound care: skin impairment to tissue between thumb/index finger (L) hand-resolving...pain (with) trying to open thumb to visualize wound (secondary to) severe contracture." * 8/5 - "Wound care: area of skin impairment to webbing between thumb/index finger (L) hand: (No) yeasty odor noted, splint in place. Scant amt (amount) of tan drng...Fingers, hand severely contracted..." * 8/14 - "Wound care: ...open area measures approx(imately) 1 x (by) 0.4 x 0.1 cm (with) foul odor, dried sang(uinous) drng...Cleansed...placed Alginate to open area, secured (with) gauze wrap to keep fingernails from digging into skin (secondary to) contractures. Soft splint replaced..." * 8/21 at 9:30 a.m. - "NSG...wound assessment to (L) hand between thumb and 2nd finger. (No) odor present. Contractures tight...Posey placed in hand to keep fingernails from causing further damage. To clarify: suspect initial breakdown d/t (due to) increased contractures (and) fingernails breaking the skin. Because of moist status, fungal component to wound came into play = use of antifungal powder... * 8/23 at 9:30 a.m. - "NSG...Left hand contracted, dressing change x 1 to wound (at) underside of thumb proximal to hand..." * 8/24 at 11:50 a.m. - "NSG...Area between thumb et (and) index finger fragile pink tissue (No) open area. Seen (sic) joints cont(inue) to be very contracted..." * 8/25 at 9:40 a.m. - "NSG...Pinpoint scab covering previous open area..." * 9/4 at 11:30 a.m. - "NSG OT assessed for a splint/posey that may (increase) air flow by opening contracted fingers..." * 9/6 at 7:30 a.m. - "NSG...resolving [MEDICAL CONDITION] to underside of thumb..." * 9/7 at 9:00 a.m. - "NSG...(L) thumb area (no) open area Scab in place..." * 9/9 at 7:30 a.m. - "NSG...left hand contracted...new gauze placed (at) site of left thumb..." * 9/11 at 10:45 a.m. - "NSG...Left hand contracted (with) dry patch at skin to inner aspect of thumb, skin intact..." * 9/13 at 9:30 a.m. - "NSG...New DeRoyal hand pump in place..." * 10/2 at 6:45 a.m. - "NSG...Sm(all) purple/reddened area to thumb. Skin intact. Antifungal powder applied (with) clean hand posey." * 10/9 "Wound care: (L) hand: (No) open area...Will continue (with) inflatable posey..." * 10/16 at 8:30 a.m. - "NSG...(No) fungal odor noted. Open area to (L) thum (sic) (at) joint...Open area ~ (about) 0.5 x 0.8 cm. TAR (changed) to cleanse (with) Vashe again (and) protect from skin (to) skin contact." * 10/23 "Wkly (weekly) wound care...: L thumb (with) open circular macerated area (with) fungal odor. 0.5 cm circular (at) joint...nonadherent gauze to prevent skin (to) skin contact. Placed inflatable posey in palm..." * 10/25 at 9:45 p.m. - "NSG...(L) thumb (with) open area..." Note: None of the remaining IPN contained any documentation regarding the resident's left thumb joint skin problem. * 11/6 at 10:10 a.m. - "Seen by PCP (primary care provider) on rounds. See N.O. (new order). There was never a definitive [DIAGNOSES REDACTED]. However, the WN stated that she never considered pressure from the resident's own fingers or the splints used to open the fingers as a contributing factor to the skin problem over the left thumb joint, a bony prominence. In addition, the resident's care plan was never updated, or revised, to include the skin problem at the left thumb joint. On 10/7/13 at 11:30 a.m., the Administrator, Administrator in Training, DNS, Corporate Compliance Director, and Corporate Compliance Nurse were informed of the finding. On 10/8/13 at 1:52 p.m., a 15 page facsimile (fax) was received from the facility. This fax included "Additional information regarding F 314" with a narrative; IPN dated 9/2 through 10/25/13; an 11/7/13 Progress Note by a Certified Wound Care Nurse, Nurse Practitioner; Physician Orders; and, Physician order [REDACTED].#18. The narrative included, "On 10/9/13 the skin nurse re-assessed his left hand and felt since there were no open areas we would discontinue the vashe cleanse and charting but continue with the soft inflatable posey to his left hand to keep increased air flow...Then, on 10/16/13 the skin nurse re-assessed the left hand and noted a very small...red open area at the left thumb joint. While this was not clearly documented in the 10/16/12 NN (nurses' notes), she said it was just under the joint (vs. right over the top of it.). Since Resident #18 had just gotten over the fungal infection that was in the webbing directly under the left thumb joint, she believed this may be a reoccurrence of the fungus. Further, she stated in her note to "protect from skin to skin contact" because she felt there was increased moisture, which contributes to fungal growth. The floor nurses continued the treatment on the TAR. Then, on 10/23/13 the skin nurse re-assessed the wound and noted a "macerated" open area on the joint that had a fungal odor." It was cleaned and re-dressed...Then the inflatable posey was placed. On 11/5/13, the skin nurse felt the wound was getting worse and had too much moisture. We discussed this in depth at the weekly Patient at Risk Meeting...She (skin nurse) had planned to contact (Nurse Practitioner's name)... However, before she could do that, the resident's primary physician was in to see him on 11/6/13. ...he went ahead and assessed the wound himself. He felt it was pressure related and discontinued the splint. Further, he ordered [MEDICATION NAME] and also ordered a wound consult from (Nurse Practitioner's name). (Nurse Practitioner's name) saw the resident on 11/7/13. In her Progress Note, she wrote, "...mixed etiology pressure ulcer to L thumb: Moisture-associated [MEDICAL CONDITION] with pressure - unstageable (will probably reveal as a stg (stage) II or III). ...Unavoidable pressure related to moisture + pressure + fungus. ... Last, while the primary physician did feel it was pressure related the Nurse Practitioner (who specializes in wounds) stated this was a mixed etiology wound that was unavoidable and had been treated appropriately. She re-ordered the splint and the antifungal powder." The additional information did not resolve the issue.

Based on observation, record review, staff interviews, and review of Accident/Incident Reports, it was determined the facility failed to ensure the safety of residents from accidents, including falls, safe water temperatures, and that storage rooms with harmful chemicals inside were locked when unattended. This was true for 2 of 13 residents (#6 and #10) sampled for falls, any resident showered in the East Shower Room, and any cognitively impaired resident who could access the unlocked storage room. Resident #6 was harmed when a CNA rolled the resident off the edge of the bed and he suffered a right orbital fracture, hematoma and contusions. Resident #10 had 13 falls within 6 months which created the potential for harm. Findings include: 1. Resident #6 was readmitted to the facility on [DATE] with multiple diagnoses, which included degenerative arthritis, [DIAGNOSES REDACTED], chronic pain, dementia, congestive heart failure, hypertension and chronic obstructive pulmonary disease. Resident #6's age at the time of the fall was [AGE] years old. The resident's annual MDS dated [DATE] and/or quarterly MDS dated [DATE] documented the following: * Resident totally dependent on 2+ staff for personal hygiene * Resident has ROM limitations in upper and lower extremities on both sides * Resident height 65" and weight 195 pounds Resident #6's Fall Risk Assessments for 2/28/13 and 12/7/12 showed the resident at high risk for falls. The resident's ADL Care Plan dated 3/5/13 documented under the Bed Mobility section "to handle with care as hx (history) RT (Right) hip/and leg bones pathological fractures." The Personal Hygiene section documented, "Total 1-2 assist for peri-care." The Side Rails/Safety section documented "Bed lowest position when occupied. Full rails down. Concave mattress, alternating air, 15 minute checks." An Accident/Incident Report dated 5/6/13 documented CNA #9 had changed Resident #6 in bed and the, "resident fell off the side of the bed, large hematoma above the right eye." The resident was sent to the ER (emergency room ) via ambulance for evaluation. An Emergency Department (ED) report for Resident #6, dated 5/6/13, documented the resident, "presents moaning and repeatedly exclaiming in pain, nonverbalizing." The Objective Assessment section documented, "the right eye is swollen shut with ecchymosis (hematoma) of the upper lid." A CT (Contrast) scan of the head dated 5/6/13 reported slightly depressed right orbital floor fracture (fracture of bones surrounding the eye), large right preseptal (nasal septum) orbital hematoma, and blood within the right maxillary sinus. The final [DIAGNOSES REDACTED]. An Investigation Report form (IR) dated 5/10/13 documented, "staff mistake." CNA #9 documented in his personal statement dated 5/7/13, "I turned him to one to start cleaning a side (sic). I got him clean and rolled up his liner and peach pad on him and tucked it under him. I forgot to put up his rail and turned him on to the other side and was going to perform the rest of pericare but had to change gloves, so while having my hands on him I reached for the box of gloves on the bed. As I did, he complained of hip pain and started wiggling and he fell of the bed." The IR Summary findings document CNA #9 should have rolled Resident #6 towards him instead of away from him and should have had supplies within easy reach. The summary documented contributing factors included the resident is obese and there, "was not a lot of room on the bed after being turned," had pain issues and was uncomfortable and moved. The IR Summary documented the CNA made a mistake by rolling the resident away from him instead of toward him and, "not having incontinent supplies ready and handy." The IR documents corrective action taken included the CNA received disciplinary action for rolling the resident away from him when providing cares. The Care Plan was updated to have 2 staff provide incontinent care. On 8/16/13 at 10:30 AM, the DON was interviewed about the proper procedure for rolling a resident to provide cares. The DON stated she didn't know but would look it up. She referenced a book titled Nursing Assistant, copyright 1998, and then suggested we talk with the Wound Nurse as she does training of CNAs. At 10:38 AM, the Wound Nurse was interviewed about proper procedure for rolling a resident to provide cares and she stated rolling a resident towards you is the proper procedure. A fax dated 8/19/13 from the facility documented after further investigation, the CNA had been trained to turn the resident away from him during peri-care. The faxed document indicated administration spoke to the (Facility) CNA instructor on 8/16/13 who showed them a book the CNA was taught with, however, the fax did not provide a book title, edition or year. The facility stated, "after re-looking at this, we believe our initial conclusion in May was inaccurate." The facility also reported the CNA could not have predicted Resident #6 was going to start "wiggling" and have hip pain during this peri-care incident. Progress Notes dated 4/18/13 (prior to fall) document, "He still gets PRN Norco 7.5 1-3 times a day, and has been on scheduled MS (morphine sulfate) 60 mg BID since 1/29/13." Review of the resident's MAR's for April of 2013 document the resident received Norco 7.5 mg/325 mg 1-2 tabs PRN pain 49 times for hip pain. Between 5/1 - 5/6/13, prior to the fall the resident received Norco 11 times for hip pain. Resident #6's Staffing Report for the Annual MDS assessment dated [DATE], and the Quarterly MDS assessment dated [DATE], documented "Pain will always be an issue." Mosby's Textbook for NURSING ASSISTANTS, 6th Edition, Copyright 2004, Chapter 13 Body Mechanics, moving the person to the side of the bed, page 249, documents, "Rock backward to move the lower part of the person toward you. Repeat the procedure for the legs and feet." Additionally, on page 250 in "Focus On Older Persons" it documents, "Many older persons suffer from arthritis...it is best to use the logrolling procedure..." When logrolling the person, page 253 of Chapter 13 Body Mechanics, documents to roll the person toward you, or use a turn sheet. The facility failed to ensure the safety of Resident #6 was free from falls. The resident experienced harm when a CNA rolled the resident off the edge of the bed on to the floor resulting in pain from an orbital fracture, hematoma and multiple contusions. 2. On 8/13/13 at 8:20 AM, the water temperature in the East Shower Room was found to be at 133 degrees Fahrenheit (F). The Maintenance Supervisor (MS) witnessed the 133 degree F temperature and stated it was too high. The MS stated he would turn down the thermostat. Later at 9:35 AM, the water temperature was checked again by the surveyor in the East Shower Room and was found to be 126 degrees F. The MS checked the temperature with his thermometer which confirmed the water temperature was 126 degrees F. The MS stated he would turn down the thermostat again. At that time the MS contacted a professional plumber to recalibrate the water temperature. Water temperature can reach hazardous temperatures which put residents at risk for burns caused by scalding. Water temperature at 133 degrees F for 15 seconds can cause a 3rd Degree Burn. 3. During the Environmental Tour on 8/14/13 at 3:00 PM, the storage room next to the Common Area was observed to be unlocked. The storage room contained: Denture Cleanser (12 boxes), Body Wash, Turbo Clean (Cleanser for jet tub, 8 gallon containers), Cid-A-L II Disinfectant (3 gallon containers), numerous containers of Natural Bath Oil which stated for external use only. The MS was present and stated the closet should be locked. 4. Resident #10 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's Significant Change MDS dated [DATE], coded the following: *Sometimes has the ability to understand others and make self understood, *Inattention and disorganized thinking - behavior consistent over time, *Cognition is severely impaired, *Extensive assist of two people for transfers, bed mobility, toileting, and personal hygiene. *Total assist of two people for bathing. NOTE: The only dates documented on the following care plan was the "Origin dates" which indicated the original date the "Problem was identified and the "Estimated Date" which indicated the date the identified goal should be met. It could not be determined when the Care Plan Focus Area and Intervention areas were reviewed or revised. Resident #10's Care Plan documented the following: Problem #5 dated 9/14/12, Potential for Falls/Fall Prevention documented the following interventions: * Evaluate risk factors & modify as needed for fall prevention: see fall risk assessment form in MDS section. * Keep bed in low position; ergonically (sic) correct for safe entry/exit from bed 12/22/12. * Orient to surroundings, and introduce self when entering room. * Fall risk assessment quarterly and prn. * Continue toileting program already in place. * Keep in line of sight when agiated (sic) or with intrusive behaviors. * Falling star program will be initiated when fall occurs and for 30 days following a fall. Note: A resident on the falling star program has a star placed on their name plate outside of his/her room to alert staff that the resident is at increased risk for falls. As staff walk down the hall they are to look in the rooms of those residents with the stars to ensure the resident is safe and assess potential needs. The following documents were reviewed: Accident/Incident Report, Resident Incident Report, IPNs in the resident's record and the Fall Scene Investigation Report (FSI). Resident #10 had thirteen documented falls between 2/17/13 and 8/12/13, including the following: - On 6/6/13 at 2:45 a.m., the IPN documented, "...Resident found on floor crawling out of bedroom into the hall. States, '..be quiet (husband's name) sleeping,' Appears to have gotten out of bed onto the floor." * The Accident/Incident Report included the following documentation under describe accident, "... appears she crawled out of bed (and) to the doorway to get assistance..." Documented under, if unwitnessed investigate accident cause, "...No fall noise was heard believe pt (patient) got out of bed and crawled to bedroom doorway." Documented under Description of preventive measures taken to prevent incident/accident from recurring.. "assessed pt (patient) continue to anticipate needs." - On 6/25/13 at 8:20 p.m., the IPN documented, "Res(ident) had a slide from chair injury...receiving hematoma to (right) forehead..." * The Resident Incident Report (RIR) documented, "Res(ident) has a habit of pulling on objects to self propel w/c. Pulled at table edge in dining area, lost balance and slid out of w/c hitting right side of head on floor receiving a hematoma." ** The FSI documented the following: "What appears to be the root cause of the fall? WC cushion did not have cover on it which made it slick." "Describe initial interventions to prevent future falls. Will order wedge cushion. Added cover to wc cushion." - On 7/29/13 at 1820 (6:20 p.m.), the IPN documented, " (at) 1540 (3:40 p.m.) resident was found in (sic) floor in front of her w/c in her room. States she hit her head...(Resident's name) has been extremely agitated this shift prior to accident." * The RIR documented, "Resident was in room. Staff heard a loud noisy (sic) from her room. Upon staff entering, resident found on floor in front of w/c on her back. States she hit her head." ** The FSI documented the following: "Factors observed at the time of fall. Wheel chair brakes unlocked." "What type of assistance was resident receiving at time of fall? Alone and unassisted." "What appears to be the root cause of the fall? Agitation (increased) behaviors (secondary) to dressing (change) to LE (lower extremity)." "Describe initial interventions to prevent future falls: "Monitor more closely when agitated (secondary) to signif(icant) others visit." On 8/3/13 at 8:30 a.m., the IPN documented, "NIF (non-injury fall) see attached accident report." * The RIR documented the following, "Staff heard resident calling out for (husband's name) checked on res(ident) found res(ident) sitting on floor next to bed. Res(ident) stated I should not have tried to get up by myself. Res(ident) fell between her bed (and) roommates." ** The FSI documented the following: "Factors observed at time of fall. Resident demented." "What type of assistance was resident receiving at time of fall? Alone and unattended." "What appears to be the root cause of the fall? Dementia and poor safety awareness." "Describe initial interventions to prevent future falls: Already on the falling star program. Do not leave unattended in room in w/c." On 8/12/13 at 8:00 a.m., the IPN documented, "Res(ident) had NIF (non-injury fall), see accident report." * The RIR documented the following, "Res(ident) found lying on her (right) side (at) the foot of her bed. Res(ident) stated she was chasing dog out the house." ** The FSI documented the following: "What type of assistance was the resident receiving at time of fall? Alone and unattended." "What appears to be the root cause of the fall? Dementia, poor safety awareness..." "Describe initial interventions to prevent future falls: Motion alarm at bedside when in bed. 8/13/13" On 8 /14/13 the DNS and Administrator were interviewed about Resident #10's multiple falls. No additional information was provided at that time. On 8/19/13 the Bureau of Facility Standards received additional faxed information from the facility regarding the resident's falls and the supervision provided. The fax documented in part: - "After the 2/17/13 fall, the resident's care plan was updated to say, 'Keep res(ident) in line of sight when agitated. The Accident/Incident Report dated 2/17/13, "Res(ident) found on floor on her left side...It appears as if she were (sic) to get in closet and pulled herself out of w/c." The Accident/Incident Report dated 2/22/13, "Suspect res(ident) was attempting to toilet self (and) fell ." The Accident/Incident Report dated 2/24/13, "Resident stood up at sink- w/c rolled backwards (and) res(ident) fell landing on Right side..." None of the above Accident/Incident Reports documented the resident was agitated prior to falls. Each Report does however, documented the falls were associated with the resident's unmet needs. - "On 4/12/13, she (Resident #10) was moved to a room closer to the nurse's station." The facility indicated this intervention met the definition of increased supervision; however, Resident #10 had 5 documented falls after 4/12/13 when her room was moved closer to the nurse's station. - On 4/29/13, "This resident (Resident #10) was moved to the secure behavior unit. That alone increased her supervision as there is a higher staffing ratio." Resident #10 had 5 documented falls after she was moved to the secured behavior unit which had a higher staffing ratio. The facility's failure to ensure that interventions were implemented correctly and consistently, evaluate the effectiveness of the interventions, modify and/or replace interventions as needed and evaluate the effectiveness of the new interventions led to the continued falls for Resident #10.